All right, so now we're going to focus a little bit more on the hospital setting rather than the outpatient setting and some of the issues that are going to come up with helping people who have opioid use disorder in the hospital setting. So we're going to talk about kind of identifying and treating opioid withdrawal in patients who are hospitalized. We're going to talk about kind of thinking through which opioid agonists we're going to use to treat withdrawal depending on the patient's situation. We're going to talk about managing pain, acute pain in people who are opioid dependent and then in discharge planning and transitions of care for patients on buprenorphine. So I'm going to start with a case study. This was a patient of mine. So a 25-year-old fellow. He uses heroin at that time, not fentanyl, the times have changed, and methamphetamine. He uses IV. He lives in Homer. In the past, he had been on sublucade. He'd been doing really well on it, but he kind of fell off the radar. Haven't seen him for about six months. He presented to the emergency room with back pain. He actually presented three times to the emergency room with back pain, initially labeled as a drug seeker until they realized he had an epidural abscess. It's a perfect example, too, of the stigma related to substance use disorders and the way people are sometimes mistreated by the medical system. So of course, he was medevaced to Anchorage for surgical management of his epidural abscess. He had over a week in the hospital recovering from that. And while he was in the hospital, they wanted to manage his opiate withdrawal symptoms, which is great. They started him on methadone for that, to manage his opiate withdrawal, and they gave him a little bit of extra opioids while he was there to help manage his post-surgical pain. He was on 30 to 40 milligrams of methadone a day in the hospital. So after he had sufficient inpatient treatment and his surgical management, he was stable, they sent him home on rifampin and levofloxacin, as well as a one-week prescription of methadone to manage his pain, and told him to follow up with his primary care doctor in Homer. We'll come back to that later about how that. So of course, unfortunately, there was not any outreach to myself or other addiction medicine provider during his stay. Certainly, they made an attempt to manage his opiate withdrawal, which is great. I want to acknowledge that that was a good thing that they tried to do. But of course, he lives in a place where there is no methadone clinic. He did not come back to see me. He went to see another primary care doctor for his follow-up, who refilled his methadone for a week, and then he fell out of care, went into withdrawal, ran out of his medication, and went right back to IV heroin use. And it took him about another three or four months to get back into care with me. So as we're talking about managing people in the hospital, just kind of think about this case and how kind of a different approach to managing his withdrawal and his pain and his discharge planning might have helped him to transition back to buprenorphine and avoid this return to use that he experienced. So many of our patients who are hospitalized have substance use disorders. One in nine, I think that's way underestimating. It obviously depends on the population that you're serving. But substance use disorders are incredibly common in our inpatients. And a lot of people have more than one substance that they're dealing with. Again, many people are also using methamphetamines. Sometimes we have alcohol comorbidities and other things like that. And we know that people who have substance use disorders are significantly high risk for emergency room visits, readmission, and mortality. And hospitalization is really a high-risk touchpoint. So we have this time, you know, where patients are sort of a captive audience where we're able to offer them access to treatment that they otherwise, you know, might not be willing or able to access in their day-to-day lives. We know that it's a very high-risk patient population. So patients who are hospitalized with an injection-related infection are more than 50 times more likely than the general population to experience an overdose after they leave in the next year. And in a number of studies looking at patients who are hospitalized who had OUD, their risk of dying in the next year is almost 8%. That's incredibly high risk of mortality. That's similar to the risk of dying after you've had an acute MI. So we know that, you know, your risk of dying after you have an acute MI is about 7% in a year. We would never, ever send a patient home with a statin or aspirin or, I don't do cardiac care anymore, so I don't know what the standard of care is. But we all know, even if we don't know, maybe they're from out of state, maybe they don't have a primary care, maybe we have no idea where they're going to go after this, but we sure as heck wouldn't let them leave the hospital without the standard of care medications to prevent. And those medications only reduce death by about 20%, 25%. And yet we still have patients sent home after an overdose or an opioid-related hospitalization without medication for opioid use disorder, and those reduce mortality by over 60%. So it's a huge injustice that we are not consistently providing the standard of care for this life-threatening disease. So why should we start medication for opioid use disorder in the hospital? So about two-thirds of people, if you ask them in the hospital, they do say that they are interested in reducing or stopping using their substance. They may not know how to do it, it may not feel realistic at that time, but they have interest in it. And if you start patients on buprenorphine when they're in the hospital, it dramatically reduces the chance that they're going to be readmitted by like 50%, so we can help to keep people out of the hospital from coming back. And we know that the patients who have opioid use disorder, when they're hospitalized, they have a really high rate of leaving AMA, patient-directed discharge, up to a quarter to a third of patients might leave. And I think anyone who does hospital care, you might have had this experience where you had someone in for endocarditis, or maybe they had a major trauma, and they end up leaving AMA before their therapy was finished, and then of course you get complications and readmission related to that or death. So we know that medications for opioid use disorder significantly reduce the risk that patients are going to leave against medical advice. And I have lots of articles about hospital care with buprenorphine. If you want more information about this, I have a bunch of references that I can share with you. So let's talk first about managing withdrawal and how to choose which medication to use to manage that withdrawal, because managing withdrawal is the very first thing you need to do. You can't even touch someone's pain until you manage their withdrawal first. Opioid withdrawal is one of the absolute worst things that anyone can suffer. So I like the descriptions that this gives from people who have gone through it. The sickest you've ever been, suicidal thoughts like you're never, ever going to get better. Sweating through my sheets, I wanted to tear off the skin off my body, I like this one a lot. It feels like the day your wife left and your kitten died, and there were no more rainbows anywhere, and there never will be again. So I think it's really important to acknowledge that it's not just physical pain that opioid withdrawal causes, it's severe psychological pain as well. People can get suicidal when they're experiencing opioid withdrawal. It's incredibly painful both to the mind, body, and spirit. So we have a couple different choices. Three main choices when we're going to treat opioid withdrawal. We can choose buprenorphine. So that generally should be started in all patients prior to discharge if they want to continue buprenorphine as an outpatient post-discharge. So that's going to be your medication of choice. Even if you don't start with that, we at least want to get people on it before they go home. If that's in Alaska, most geographical areas of Alaska, of course, we don't have access to methadone. There's only six methadone clinics in Alaska, I think they're located in just your major metropolitan areas. You have to go there physically every single day. So for most areas of the state geographically, that is not an option for people. But if you have patients who do live in the urban areas, it is important to talk with them about methadone to see if they are interested in methadone. Methadone can only be given out at a methadone clinic or an OTP is what they're called. It's very highly regulated. They have to go there physically every single day. It's an incredible amount of work on the patient's part and requires just an incredible amount of commitment on the patient's part to do that. But some patients really like the idea of methadone. You can get very high doses, you can get good pain control. So that's great. If they want to do that, then perfect. And then you should start methadone when they're in the hospital. But you shouldn't probably be starting methadone in the hospital if that's not going to be the medication that they can access afterwards. Also methadone has a lot of issues around how quickly you can increase the dose on it, right? Especially in the methadone clinics, they're very restricted on how quickly they can ramp up the dose on it. So a lot of times in the hospital, you're not going to have enough time to ramp the dose up high enough to actually get their cravings controlled to get them to a therapeutic level before they leave the hospital. But it is an excellent thing to start for patients who live in urban areas and they do want to go to an OTP for treatment after they leave. Now full opioid agonists. So we can absolutely treat opioid withdrawal with full opioid agonists. And we can do this in combination with these other medications. So we can have buprenorphine or methadone as kind of the baseline. And then we can add on top of that a potent opioid agonist such as hydromorphone or fentanyl. And those particularly, it doesn't matter so much when you're combining with methadone, but when you're combining with buprenorphine, hydromorphone and fentanyl are better able to compete with those available opioid receptors. So they're just more effective choices to use to treat pain. So when people have really severe pain, we can use a PCA or just very high doses of these medications even if patients are on buprenorphine. These also can be really useful to treat very severe kind of intractable precipitative withdrawal. So if we have a patient who's tried to start buprenorphine at home, they went into severe precipitative withdrawal, they've already taken 40, 50, 60 milligrams of sublingual buprenorphine and they're still writhing and puking, that's when we can give people fentanyl or hydromorphone in the emergency room to manage their precipitative withdrawal. So I'm not going to talk a lot about starting methadone here, but I do want you to know there are some good resources. This is a really nice, very simple algorithm, again, from the Bridge to Treatment Program that talks about kind of how you can start methadone in the hospital. The most important thing is collaboration with the OTP, with the methadone program. So you need to have your case manager, whoever it is, especially if they're not already a patient there. If they are a patient there, you want to call, you want to verify their dose, you want to verify when they last got a dose. If they aren't a patient there, you want to verify that they don't have a waiting list, that they're able to get them in right away. You want to find out what restrictions they have. Do they allow patients to take benzos? Do they, you know, what other comorbidities are going on? So that you know that that discharge plan is clear. When they leave, that they have a spot ready to take them at the OTP and they have a way to get there and all that kind of thing. It's also important to understand that with methadone, there are numbers of case reports of being able to, like in the supervised setting in the hospital, you can actually increase methadone pretty quickly. You know, you have to be cautious with methadone because you give the dose of methadone and it takes three or four days to build up to actually see that full effect. So you have to be really cautious about how quickly you're increasing the methadone dose. And OTPs are very strictly regulated. Like that first week, they pretty much cannot give more than 40 milligrams a day of methadone. And then they can only increase like 10 milligrams at a time. So it can take people two months of being in a methadone clinic before they get up to therapeutic levels that are control their cravings. And so used to be that we would see, you know, 60 to 100 milligrams of methadone and now we're seeing more like 100 to 180 milligrams of methadone. I had someone come in from out of state last month who was on 175 milligrams of methadone who moved to my town. We had to switch them over to buprenorphine and that was quite challenging. So yes, you can escalate the dose quickly, which may be a very good thing for you to do under the close supervision. And you can look more into like some of the protocols on doing that, especially in a person who's previously tolerated high dose of methadone well. However, you need to make sure that the OTP is okay with continuing that dose. So if you get them ramped up, you have in the hospital, you get them ramped up to 80 or 90 milligrams of methadone, though you send them to the OTP, they may legally not be able or willing to continue that prescription. They're going to drop them back down to 40. So it's really, really important to collaborate with the OTP before, you know, as you're figuring out what doses of methadone to give people in the hospital. So we're not going to talk more about methadone, but it's just, there's lots of research. If you want to reach out to me, I can connect you with some more research about methadone. So we're going to talk more about starting buprenorphine in the hospital. So when we think of traditional approaches to prescribing, to doing buprenorphine, which the traditional approach is, you know, stop your opioid, wait 12 to 24 hours, wait until you're really uncomfortable, and then start your buprenorphine. That really is not easy or realistic to do in the hospital a lot of times. First of all, the patient's going to be really uncomfortable. If the patient is in there, which they very often are for a painful, acute, painful condition, completely stopping all of their opioids for 12 to 24 hours, they're going to be miserable. They're probably going to leave AMA. They're going to drive the nurses crazy, right, because they're miserable. They're going to make the nurses miserable. And it's just a lot, way more work on the nurses' part of like constantly checking the withdrawal scores and that kind of thing. So it's really challenging to start buprenorphine in that way in the hospital. It can, for sure, be done in certain circumstances, but it's not easy to do that. So the new approach that most hospitalists are using is what you might hear called microdosing, but the kind of accepted terminology is a low-dose overlapping start. So who do we want to consider this in? So patients who are transitioning from methadone to buprenorphine, because methadone, if you look at the instructions and the prescribing information on how to switch someone from methadone to buprenorphine, they'll say, well, they have to be on 30 to 40 milligrams or less of methadone, and they have to be stable at that dose for at least a week. And then you've got to stop for 48 to 72 hours, and then you can give the first dose of buprenorphine. That's just not going to happen. So the low-dose overlapping switch allows the patient to continue the methadone, and then while they're starting to take their buprenorphine, and then they don't stop the methadone until they're up to therapeutic dose of buprenorphine. So that's what I did for my patient, which she had 11 days of take-home methadone from California when she came up. So we were able to successfully switch her over to buprenorphine in the outpatient setting doing that low-dose overlapping. People who have chronic fentanyl use, especially when you ask them, you know, have you taken buprenorphine before? And they give you that response of every time I take it, I get super sick, that those might be patients that would be a good choice for this. Anyone who has a severe acute painful condition, you know, they're there because they've had surgery or because they have a trauma, that we don't want to have to stop any pain medications. We want to keep their pain controlled the entire time. And just in general, people who have just not tolerated traditional starts due to precipitative withdrawal symptoms in the past. So the basic overview of a low-dose overlapping switch is we're going to allow patients to discontinue the whatever full opioid agonist that they're taking. That could be the methadone, it could be your hydromorphone or fentanyl. In the outpatient setting, it's whatever their drug of choice is. And then we're going to start with tiny, tiny little baby doses of buprenorphine that are not enough to knock all the other drugs off their receptors. And we're going to slowly increase that dose every day. Essentially, most protocols you'll see will double the dose every day until you get up to a therapeutic dose. So you're slowly replacing the full opioid agonist with buprenorphine on the receptors. And so you might experience some amount of withdrawal symptoms, but they're going to be really minimized. It's going to be a much more comfortable situation for the patient. And then when you get to a therapeutic dose of buprenorphine, then you're going to stop the other full opioid agonist. This is still kind of like somewhat limited evidence, but there have been actually, in the last two years, there have been multiple meta-analyses and things that have been published that show that this technique, it is like the standard of care in hospitals now who have addiction medicine departments. And there are multiple meta-analyses that show that it seems to be very well-tolerated and effective. So this is the most common protocol that you will see for a low-dose overlapping switch. This was published two years ago in the Journal of Addiction Medicine, that starting at a half a milligram. So most commonly, you can do this with tablets or films. The films are easier to cut. Sometimes you deal with issues in the hospital pharmacy with their formulas, what they allow you to do. And sometimes they don't allow you to cut strips or they don't allow you to cut them into certain size pieces. So there's other protocols that use other formulations. But usually, we start with a quarter of a two-milligram strip, so it's half a milligram. And then we double the dose every day until we're getting up to more than 12 milligrams, 16 milligrams or more. And then we can stop the other opioid agonists, and then we can give them whatever dose of buprenorphine that they need after that, as high as they need. There are alternatives to this that are, you can go faster or slower. So you can adjust this completely according to what your timeline is and the patient's goals. Like for my patient, who was on 175 milligrams of methadone, she had 11 days supply, so that was our timeline. We had 11 days to do this. So we went up significantly slower. We went, I think we went from half a milligram to one milligram to two milligrams to three. We went up one milligram a day instead of doubling it until the very end, and then we just kind of slammed the buprenorphine. She never experienced precipitative withdrawal, which I thought for sure she was going to have in the hospital, and she didn't. So that was wonderful. Or sometimes you're in a rush, because like, hey, this patient's got to go home in three days probably. We had to get this done quickly. So there are a couple of protocols that are like one and three-day protocols, where you kind of combine, you start out very slow, and then towards the end, you kind of hit them with a really big dose at the end. And a number of these also include, let's see here. So this is one, this is a three-day protocol. You're using hydromorphone here as the kind of drug to continue. And during this course, when you have someone in the hospital, any breakthrough withdrawal symptoms that you do have, you can just treat those breakthrough withdrawal symptoms with the opioid of choice. So you can just get, not methadone, you don't give methadone PRN for pain, but whatever you're using PRN for pain, hydromorphone or fentanyl, you can have as needed doses for breakthrough symptoms as you're doing this. And then essentially, once you get up to, you know, eight milligrams or more of buprenorphine in this protocol, then on the third day, they administer a supplicate injection. It takes 24 hours after you administer a supplicate injection to reach peak serum drug levels. So that's another thing to consider, is that that first day that people have their supplicate, they still need probably high-dose buprenorphine along sublingual, and 24 hours later, then they'll have nice high therapeutic drug levels. This is a one-day micro macro start. This is on the California Bridge. So this, they're using the patches, which you can't use in an outpatient, but you can use as an inpatient. So they're putting two patches on, or another alternative to this is, they talk about here, or you can do a quarter of a strip, or you can swallow a two milligram sublingual buprenorphine, which you'll only absorb a tiny bit of it, but you'll absorb, you know, just enough to, and you can repeat that every couple of hours, and then once they develop moderate to severe withdrawal later in the day, then you give them the really high dose of 16 to 32 milligrams of buprenorphine. So lots and lots of different approaches that are out there, and so you can really adjust it depending on what the patient's need is. How much time do you have to work with this? Because the thing to remember about all these protocols is that they're a lot more complicated than the standard instructions that we're giving patients as an outpatient, right? And if I have this seven-day protocol of doubling the dose every day, and taking it two or three times a day, that can be really, really hard for patients to follow as an outpatient. So it's, this is actually, I have for sure had patients that did it as an outpatient, and they did it successfully, and it worked great, but you have to have a patient that is able to follow those instructions, they're able to track every day the exact amount they're supposed to take, they're able to communicate with you when they're having problems. So as an inpatient, it's actually a lot easier because we can manage breakthrough symptoms, we're dosing the medications, so we have the control over that, that patients might be difficult for them to do on their own at home. High dose, so high dose starts in the hospital, that's the other option. So that when we don't have the time and we need to get things done quickly, so like the emergency room is usually where we use this. And this is just a little bit more of a kind of the philosophy of, probably should have shown this earlier, but some of the philosophy of what's happening here. So when we have all of the opioids, all the receptors bound with a full opioid agonist, this no man's zone here of like two to eight milligrams is the dose of buprenorphine that's most likely to cause precipitated withdrawal. So when we give just enough buprenorphine to knock all the medications off of the receptors, then we end up with, there's no opioids on the other receptors, but we only have a little bit of an agonist effect. So we're in there precipitated withdrawal. Versus if we displace the opiates off for the receptor and we have a really high dose of buprenorphine, then we're getting all of the receptors saturated with buprenorphine and we have much more opioid agonist effect. Because remember, you can't relieve the symptoms without an opioid agonist effect. So this will allow you, you know, when you do the high dose starts, you can get people therapeutic as quickly as possible. Especially when you're dealing with someone from the emergency room, someone who's going to leave AMA, you want to get them therapeutic as rapidly as possible to get them protected and rather than taking days to titrate up on the dose. So a high dose start is good for people who have high levels of opioid tolerance and they need to get rapid symptom control or rapid therapeutic levels. And ideally with a high dose start, we're going to want to wait until the patient is in withdrawal. So that might be tricky to do, like sometimes you have someone who's in the emergency room but they're not in withdrawal yet in the emergency room. Maybe they're there for an infection or something else but they're not going to be going home, they're not going to be staying. So that might be where we're going to send them home with the instructions for the high dose start because they're not quite ready to start it yet. But again, similar to what we talked about before, we're going to give 16 milligrams to strips or tablets. That's going to be the first dose and then repeat that every hour as needed. Another 8 to 16 milligrams until you get, you know, which require 32 to 40 milligrams at times. Especially again in the hospital setting, you have that ability that we don't have to worry about the insurance outpatient pharmacy issues. We can give them as much as they need to control those symptoms. So let's go back to this case again about this fellow. What are some of the issues that you see with this case and what are some ways do you think that this could have been handled differently in retrospect? Anyone have any ideas? Yeah. Yeah. So we have the PDMP, right, that you can check when these people come in and see, oh look, this person six months ago, they were seeing this addiction person. Someone was prescribing them buprenorphine and they were on it for six months. Maybe that person knows about this patient and would be willing to take them back. Yeah. Plus especially if you don't, if you don't feel very comfortable with buprenorphine, maybe you're new to prescribing it, that buprenorphine prescriber, they may have a very high level of comfort. They know, we know our patients so well. We see these patients, I see some of these patients every week, every month for years and years. You get to know patients so well. You know all their ins and outs of their social situation. They're an incredible resource to you. So look at the PDMP and reach out to that buprenorphine prescriber. Yes. What else, what other things could we have done differently to improve his outcome? So what about the methadone? Because he's going to be going to Homer. Yeah, there's no methadone clinic in Homer. So that's really important to know before you start that first dose of methadone. Where do they live? You know, asking them where do you live? Do you want to go to the methadone clinic after you leave here or not? And if they say they don't want to go to the methadone clinic or they're not really sure, it's very easy to switch from buprenorphine to methadone. No problem. Very easy to do. It's difficult to switch from methadone to buprenorphine. So when in doubt and the patient doesn't know, the safer bet is to do methadone to control their withdrawal symptoms in the hospital. I'm sorry, to do buprenorphine to control their withdrawal symptoms in the hospital. They can always change their mind later and switch to methadone. That is very easy to do. So when in doubt, start with buprenorphine. And let's see here. So some of the issues. So first of all, again, so we talked about, you know, didn't reach out to addiction provider. We can't give methadone in his home community. Methadone at the—so he's on 30 to 40 milligrams of methadone. That's not therapeutic methadone doses. That's not enough to suppress his withdrawal symptom. It might be enough to suppress withdrawal, but it's not enough to suppress cravings. Typically, we're going to need doses of 60 to 120 milligrams to suppress cravings, and we're not usually going to get there before the person leaves the hospital. So that's really important to understand, is that when they discharge on that, they likely will return to use. Also to understand that methadone is a more risky drug than buprenorphine. Inherently, it has many drug-drug interactions, right, that we have to consider. It interacts with fluoroquinolones, QT prolongation, and he was—remember, he was prescribed levofloxacin and rifampin, right? Rifampin also decreases the serum concentrations of methadone, so it's another thing to really consider. Anytime you have a patient who's coming in on methadone or you're starting methadone, I never prescribe any medications to someone who's on methadone without doing a drug check. In hospital—hopefully, the hospital, you have your pharmacist, and they're going to catch those things, but like, it's better as a provider. We should be double-checking ourselves and always looking for drugs, even like—like on danzatron, Zofran, right? That's QT prolongation. So I didn't actually give that to my patient who I did the switch over because I was a little worried about that in the outpatient setting, especially with her super, super high doses of methadone she was taking, so just be aware of that. So it—regardless of how this started, you know, maybe during surgery, they were just using hydromorphone or fentanyl. Maybe they did give methadone the first couple days, but regardless, he's there for enough days that you have the option to do a low-dose overlapping switch for him, even if it's a three-day one or a five-day one or a seven-day one, to get that—do whatever you need to do to get the buprenorphine restarted as an inpatient, ideally. Or worst-case scenario, maybe you do send him home with a week of methadone for pain, but you also give them on the instructions to do the switch after they leave the hospital. That's not ideal. Ideally, we really want to get them on their treatment of choice before they leave the hospital. Okay, so let's talk a little bit more managing precipitated withdrawal in the hospital. So the standard treatment is we're going to use really high doses of buprenorphine. If someone's in the emergency room, you can also—you have other options to do. So if you're getting up to 40 to 60 milligrams of sublingual buprenorphine and they are still miserable, that is kind of that area where you're thinking, okay, this might need to be managed in the emergency room, especially with very severe symptoms, you know, like intractable vomiting and that kind of thing. So we can use a little bit of benzo, just help the person relax. We don't want to snow them with benzos because, again, that's not going to fix the underlying thing. Like when people just pour, you know, they're giving people high doses of benzo and high doses of, you know, Cyprexa and like all these other medications, like you're just snowing them. You're not addressing the underlying issue, which is the opioid deficit. You have to address the opioid deficit. Ketamine, there is something about the NMDA antagonist effect of ketamine that makes it particularly effective at treating buprenorphine precipitative withdrawal. We don't understand completely how that is, but it can be very effective at relieving symptoms. So if you have a patient with this and you're in a hospital setting where you can administer low-dose IV ketamine infusion, I would highly encourage you to take that approach. And then a high-potency opioid of choice, so fentanyl or hydromorphone. And then there are other things, you know, you can add, you know, all of the other adjunctive medications on it. You can try clonidine and gabapentinoids and you give a little bit more benzos and kind of do what you need to do. And the most important thing is to trust the patient, look at the objective signs of what's going on, and to give them, you know, especially when we're thinking of giving them more fentanyl, like the worst thing that happens is that people just assume that everyone's drug-seeking, right? They're asking more fentanyl because they're drug-seeking. No, they're miserable. They're asking, they're in pain, they're suffering. Look at the objective patient, listen to what they're telling you, and look at the vital signs. And if they are not over sedated and they're telling you that they're miserable, just give them more fentanyl or hydromorphone. You know, you have to believe and trust them and not allow your internal biases to make you assume the worst about patients. And then this particular slide is from a presentation, you know, that really, really recommended if you have that patient and they're in the emergency room, they come in to manage their precipitated withdrawal, wouldn't it be great if before they left the emergency room you could give them a supplicator bruxade shot so that you don't have to worry about them taking those meds the next couple of times? Because again, it's very hard to make yourself to continue to take those medications that just made you so violently ill that you ended up in the emergency room. It's an incredibly difficult thing to ask someone to do. So if you can just give them an injection, then that, they don't have to worry about that. And it buys you more time to bridge that transition of care to the outpatient chronic care setting. Again, adjunctive medications, don't forget that you can utilize these to help with ongoing withdrawal symptoms, either in the inpatient or the outpatient setting. And these are all, you know, in reports. Benzodiazepines, I don't prescribe in the outpatient setting. Again, because it's not, because inherently they're super dangerous for buprenorphine. There's some risk in combining benzodiazepines with buprenorphine. It's that if the patient doesn't take their buprenorphine and they go back to using fentanyl, that's what I worry about. I worry about the combination of the benzodiazepine with the fentanyl. I don't worry about the benzodiazepine with the buprenorphine. But in the inpatient setting, that's fine. If you need to help their anxiety and give them a little bit of benzo, that's fine. But just don't like over sedate them with the benzodiazepines because that, it's not addressing the underlying cause of the problem. In the emergency room, so there is a growing trend nationwide towards pre-hospital initiation of buprenorphine. So this means that buprenorphine is being administered by EMTs and paramedics in the field. So there are more than 10 states that are doing this already. And there are a lot of really good reasons to do this. First of all, so EMTs, they probably have more experience than anyone else in witnessing people who are experiencing naloxone precipitative withdrawal, right? Because they're responding most commonly to an overdose. It might not be. They might be responding to someone who's in withdrawal for other reasons and they also have a medical problem and so they're wanting to go to the hospital. But the most common situation is we're seeing someone who was revived in the field by a friend with nasal naloxone. They're in precipitative withdrawal. They may or may not be willing to go to the hospital. Often they might refuse transport. If you don't treat that precipitative withdrawal, almost certainly that person is going to self-treat that withdrawal by taking fentanyl because that's the only way that they know how to relieve those symptoms. The risk of overdose in the most dangerous time after someone has an overdose is the next 48 hours. That is when they are most likely to die of a repeat overdose, is the next 48 hours. So if we can give people a high dose of buprenorphine, it has such a long half-life that that is going to, it's not going to completely prevent an overdose, but it's going to significantly reduce their risk of having a repeat overdose in those next 48 hours. Whether they, you know, refuse transport or agree to go to the hospital, either way, if they can load them up with high-dose buprenorphine, that's going to give them at least some protection. It's going to relieve their symptoms. It's going to make the patient much easier. They're going to be happier, right? They're not going to be angry and fighting you. They're going to be getting comfortable rapidly, getting comfortable, and they're going to be much more likely to engage in treatment. So typically there's a couple protocols, but typically the same thing. It's a high dose, so typically 16 milligrams is typically what's administered in the field with additional doses generally being administered if they go into the hospital, but most of the protocols are they're administering 16 milligrams in the field. Sublingual, yeah. What's that? Oh, I can't remember all of them off the... New Jersey was the first one to do it. There's like a couple of the Midwest states, a couple of the Northwest states. It's just scattering across the entire, and that's just the ones I've recently have read. There might be more that are doing it now, but yeah. I can, I have a different slide that I cut out of this that listed the states, but I can't remember them all off the top of my head. And we, there is a move toward, this is going to be happening in Alaska. So I've been working with some people from the state who are the head of the EMS director folks for the state. They are, the state has some more, some new grant funds that they are planning to set aside to provide education and training for EMTs to do this. They're just trying to figure out the logistics of that now. Where does it make much sense, like where... Here or two, you will see this happening in Alaska. This is just an example of some reports in the literature about this early on from where they started in New Jersey. Good outcomes. They found good outcomes from this without any significant complications. So this is an example of, from the bridge program of the EMS side algorithm of how to provide, of how to assess for withdrawal and how to assess for any possible contraindications. And then contacting medical control for the approval to administer the buprenorphine. And then kind of going from there, depending on if the patient's going to be transported or if they're going to be staying at home. If the patient's, you know, refusing transport, generally that includes leaving, like sometimes includes leaving a naloxone kit, leaving brochures that say, hey, this is where you can get treatment if you want to stay, if you want to get onto buprenorphine, or this is how you can get help. You know, actually, and some programs have kind of with the crisis now model and mobile integrated health care, which is also, Alaska is working towards integrating that. And to actually then, with the patient's consent, say, hey, would you be okay if we had a peer support person contact you tomorrow to talk with you about how you're doing? And if they can get the person's consent on that, then they have a peer, a person with lived experience, a care navigator, actually actively reach out to that person to talk with them about kind of what their options are, what their needs are, and try to connect them to any support services that they might need. So the current recommendations for treatment in the emergency room, I think this came out two years ago, update on the consensus recommendations on the treatment of opioid use disorder in the emergency department by the emergency medical association, where the National Association is, says that the group recommends that emergency physicians offer to initiate opioid use disorder treatment with buprenorphine, and then we should try to be providing linkage to care for treatment for patients with untreated opioid use disorder. But we shouldn't withhold treatment even, you know, just because we're not completely sure what's going to happen next. Because sometimes we just don't know, sometimes we don't have the ability to do the warm handoff. The warm handoff is always ideal if we have, you know, if this person is in the emergency room and we know there is like a local care navigator, case manager, peer support person that can reach out to that person actively. You can give them a phone number for them to text, like, do you want to get into treatment? Hey, just text this number right now, and this is a person who's been through what you're going through right now, and they're gonna help you get an appointment, and they're gonna help you get a ride to your appointment. All these kinds of things, that is, you know, the true warm handoff, that's the ideal situation. But sometimes we don't have, we don't have anything to work with. We don't have those resources sometimes, and that's okay. It's okay if, you know, if all you do is, you know, give them a dose there in the emergency room, and you give them a one-week supply, and then they go off of it. Every day that they take it is a day that that's gonna reduce their risk to their health. So, and when we start buprenorphine in the emergency room, they're gonna be twice as likely to then engage in outpatient treatment in a month as if we only gave them a referral. So that, that positive experience being treated right then when they need it doubles the chance that they are going to get into treatment. So we're much more likely to get people into treatment, and this is a while, this is from 2015, so we've known this for a while now. But there are still emergency departments that are hesitant, like, what if we do it, we're just gonna, we're just gonna, people line up out the door, everyone's gonna come here, they're just gonna be looking for buprenorphine, they're gonna be coming here over and over again, which is, I understand where that thought comes from, but it's not true. It doesn't, it doesn't actually happen. So we have, we have evidence, and what if it did? What if people, what if we did have all kinds of people come to the ER to get buprenorphine, right? The emergency room is where our most vulnerable high-risk population gets a lot of their medical care, and that is really, and that's how they get connected to care, and unfortunately, it's sad that sometimes that that's where our system works, but, but unfortunately, that this is where people get access to getting, getting treatment, so sometimes that's the way it has to be. But luckily, we've known for quite a while now that when we start buprenorphine in the emergency room, it dramatically reduces the, the risk that they are going to return to the emergency room, cuts it in half, the risk that they're going to come back to the emergency room. It dramatically reduces the, the, the chance that they're going to need to be admitted or having a readmission. It reduces the cost of the emergency room visit, and it reduces the amount of time that they have to spend in the emergency room during that visit because you get their symptoms under control much more quickly. So it's everything we want. Out of an emergency room visit, it does it all, plus it's becoming better, you know, better outcomes. So there, there really is no downside to starting buprenorphine in the emergency room, other than the fact that we, we need to have the education and, and the policies and procedures in place that we understand how to do it correctly. So again, the, the BRIDGE program really was designed initially to focus on treatment in the emergency room, and it has really expanded to like other outpatient. It has a lot of information about just hospitalist care for people with opioid use disorder, but these resources, they are, they are really targeted towards emergency room treatment. So I, and it has lots, you know, lots of training materials. It just, I'll just keep going back to it because it's such a great resource to, and they have like signs you can post in the emergency room, like, do you have a problem with opioids? We can help you here, you know, like, because sometimes people like, they're afraid to, to ask for help because they're afraid that, you know, they're going to be treated badly. So when, when you make a welcoming kind of environment that says we're here to help you, we have ways to help you feel safe to ask us for help. And this is their physician medical provider protocol on algorithm on, on dosing and monitoring the buprenorphine during that emergency room visit with kind of the tips and tricks along with that. And this is the same, the same handout that I showed in the previous slide, the, the discharge handout to give the patient to explain to them if they're in the, if they're in the emergency room, but they're not in withdrawal yet, maybe they came in for a skin abscess, right? They're not in withdrawal, but we know that they're using opioids. We can still offer them to start after they leave. We can send them home with instructions on how to start it at home. So we can still give a prescription to them for start at home, even if they're not ready to actually start it right there in the emergency room at that day. Then starting extended release, long acting injectable buprenorphine in the emergency room. So this is an ongoing study, but they published some preliminary information. So this is kind of in a handful of emergency rooms nationwide that are participating in this study. So they are administering, they're actually in this form, this study, they've actually been using, it's the one, it's the high dose weekly formulation of Brixadi was the one that they used. The kind of an advantage of, they actually was using it for years before it was approved because it was under a research protocol in the United States. Again, it was, it's been approved in Europe for a while. So some, it has very much similar onset of action to, to the sublocade, as far as it takes about 24 hours for it to reach peak effect. But of course it doesn't last as long, it only lasts for a week, but it's also a quarter of the cost because it's a quarter of the dose. It's a weekly formulation. So that can be kind of appealing to a hospital, be like, you know, hey, this medication, you know, that's, you know, $500 versus $1,700. Maybe you're more willing to stock it and keep it in the emergency room if you're worried about reimbursement and cost issues. But one of the things about, when we think about the difference between sublingual and extended release buprenorphine, when it comes to the risk of precipitated withdrawal, and this is all theoretical, but when you take sublingual buprenorphine, you get very high doses, very high serum drug levels that peak in an hour, and then they come down. So you're getting a rapid onset of, of serum, of high serum drug levels, which depending on the dose that you give, and depending on how much fentanyl is in their system, may or may not trigger precipitated withdrawal, but it's hitting you hard and fast, is kind of the, the thing with that. Versus with the extended release, it comes on slowly over time, you get about 50% of the effect at eight hours, and then it takes 24 hours to peak serum drug levels. So it's a more gentle onset of action, and that we theorize because of that is that it might be better tolerated and might have a lower risk of precipitated withdrawal. So, and this was given to patients in the emergency room that had been using fentanyl and that had not been given any buprenorphine before this medication was administered. If you're not familiar with sublocade, which is the long-acting that we've been using for the last six to seven years, that the prescribing information in that medication actually says that a patient should be stabilized on at least eight milligrams of buprenorphine for a week before you give them the injection, which is baloney. And they're actually trying to change the, they're trying to change the prescribing information, but that takes a really long time to do that through the FDA to change your prescribing information. So it will be changing, but it hasn't changed yet. So Bruxadi is labeled to be able to give it after one dose of buprenorphine. But when we think about like, what is the reasoning behind that? When you actually think of the logic, there's a couple of reasons behind that. So for one, if you have a patient who has no opioid tolerance, like they've been abstinent, they don't have an opioid tolerance. If you hit them with a super, super high dose of buprenorphine, it is not going to be well tolerated. You know, they're gonna have severe side effects. They're gonna be unhappy. They are not gonna want to get another injection again, because they're gonna be throwing up and they're gonna be sleeping and they're gonna be dizzy and they're gonna feel horrible. So if they have no current opioid tolerance, that is a reason to have them on buprenorphine for the week before that. Sublingual, so you can gradually titrate up to eight to 16 milligrams before they get their shot for tolerability reasons. So that makes sense. Patients who have no experience with buprenorphine before. This is incredibly rare. I think in the last year, I think I've had one patient come through my office who had never taken buprenorphine before. Almost everyone that's come through will be able to tell you what happened when they took buprenorphine before, whether it was prescribed to them or not. And someone who has never had a positive experience with buprenorphine before. So someone just said to patients, well, I tried it once or twice, but it made me super sick and I don't know if I like it. Well, I mean, do I really want to give an injectable form medication that I can't take it out once I put it in? You're stuck with it for a month and you don't even know if you like this medication or not yet. So that's a good reason. It's not an absolute contraindication. I've given it to someone. I've been to a couple of people who weren't sure that they liked buprenorphine because that was kind of, they were kind of stuck between a rock and a hard place. But we'd like, ideally we'd like to make sure people like buprenorphine before we give them a monthly injection. The other is the timing of their last use and timing when you're going to start the medication and trying to reduce that risk of precipitatory withdrawal. And again, this is off in the air because we really don't have a great sense of really who is at the most risk of precipitatory withdrawal or not. Cause we know it doesn't happen that often. Who's going to have to, we're not good at guessing who's going to happen to or not. But in theory, if we, you know, give patients a week of buprenorphine before they're going to get their shot, they can choose when they're going to take that buprenorphine. It's very, very hard for people to stop taking their drug of choice at a specific time and then show up at the office at a specific time in the exact amount of withdrawal. Like that is incredibly difficult to do and almost never happens the way you think it's going to happen. So if they have that medication at home, they can kind of see how their life is going over that week and they can choose when to start the sublingual to make the timing right, that it lines up right. But some patients, they just, they hate taking sublingual buprenorphine because every time they take it, it makes them super sick. Or like maybe they can take it, but then they take it like every other day or they take it a couple of days a week and then they're using fentanyl in between. They're just not able to succeed with taking the sublingual buprenorphine. So when you require that, that a person has to take the sublingual buprenorphine for a week before, you essentially are making it inaccessible to all the people that need it the most. The people that have the most severe opioid use disorder, the people that have the most difficulty starting their medications, the people who are at higher risk for overdose, who are using lots of fentanyl, those are the people who need this medication the most. And so by sticking to those kind of prescribing guidelines, you really have to think about the logic of why am I doing this and how would it change if I did this different way? So in our office, we have like a patient consent for a rapid start of long-acting injectables. And we always see them the week before via telemedicine and we give them a week's worth of buprenorphine, sublingual buprenorphine, and we encourage them to start it before their appointment. But we also say, hey, if you can't start it for some reason, it just doesn't happen, still come in to the office because we can talk and we still might be able to give you your injection if you're willing to get it. And I would say in a significant portion of patients, they do show up having not taken it, they just, they don't like to, they don't want to, whatever they meant to, but just they didn't get around, it just didn't happen. And so we do a lot of starts with no sublingual lead and we're participating in a patient qualitative kind of survey on patient experiences with the University of Washington, kind of looking at this, because there just isn't a lot of published, you're not gonna see this other than this emergency room, you're not gonna see this in the published data. So, but in our experience with our patients and we've done it dozens of times with our patients, it's generally very well tolerated. And the patients who don't, the patients who experienced precipitated withdrawal, they are the patients who always experienced precipitated withdrawal, every single time they ever tried to take buprenorphine, right, and they expect it, they know it was coming, we give them instructions on how to treat it, it's self-limiting, it's usually 24 hours, sometimes it's 48 hours, they know it might come, we gave them the medications and instructions on how to treat it, they're willing to accept that risk. And the difference is that, I'm doing this to them, they don't have to keep forcing themselves to take this medication, right, they don't have to keep forcing themselves to take the medication that's making them sick, it's much easier for them to have me do it to them by giving them the injection, and then they just have to get through the next 48 hours and then they get on the other side of it and they feel great, and they are so thankful, because then they don't have to worry about the hassle, you know, they're on it, and in theory, they never have to experience precipitated withdrawal again, ever, if they, you know, at least every couple of months keep getting a shot of buprenorphine, so it's really helped us to expand access to the people who are really struggling the most and are at the highest risk. Let's talk about acute pain management. So, when we're dealing with patients who are opioid dependent in the hospital, we're always trying to balance these, we want to get good pain control, but we also, we wanna avoid withdrawal, we wanna get their symptoms controlled, but we don't wanna trigger, you know, a return to use after they leave the hospital. So, the number one thing is that you have to treat the underlying withdrawal, if there is an opioid deficit, you have to treat that first, you're never ever gonna get the pain controlled until you get the opioid deficit and withdrawal fixed first. So, the number one thing is starting a medication, buprenorphine or methadone, that's going to treat the underlying withdrawal, and then treat the pain on top of that. Why is it difficult to treat pain in patients to buprenorphine? So, the traditional thought behind this is like, well, buprenorphine blocks opioids, so you can't treat their pain because the buprenorphine is gonna block the opioids, and that's the problem, so we gotta get rid of the buprenorphine, that was the old school thought, but we realized it's not necessarily just like the buprenorphine of itself, it's the inherent difficulty in treating pain in patients who have opioid tolerance independence. All patients who have high levels of opioid tolerance independence can be challenging to manage their pain. So, yes, buprenorphine does block some effects of opioids, it's dose dependent, but these patients do have a high level of opioid tolerance, often they have comorbid chronic pain and hyperalgesia on top of that, and also other psychiatric issues like depression, anxiety, PTSD, that can make this whole situation very traumatizing, and that's going to decrease your pain tolerance threshold. Surgery and trauma is a highly stressful and emotionally charged time for a patient, and that fear and anxiety can be misconstrued as kind of this person being histrionic or drug seeking behavior, and the person is just, you know, they're suffering and they're very anxious that they're not gonna get the care that they need because they may have had a lot of very traumatic interactions with the medical system in the past. And then if we do stop buprenorphine, that can make things worse because it can lead to withdrawal symptoms and worst case scenario, return to use if they leave without their buprenorphine. So, up to a quarter to a third of patients who use IV drugs will leave against medical advice from their hospital admission, and untreated pain and untreated withdrawal symptoms is one of the number one cited reasons that patients leave against medical advice. And it's also very common, about a third of patients who use IV opioids are going to self-treat their own pain when they're in the hospital by bringing in illicit drugs and mystery. That is normal behavior. It's not, they're not trying to get high, they're trying to relieve their pain and withdrawal symptoms because it's not being adequately done by their provider in the hospital. It should be expected. The fact that we police these patients and we strip search them and we police their rooms and we take everything away from them is just ridiculous. Like we're doing that because we're not taking good enough care of patients. If we took enough care of their pain, they wouldn't need to be sneaking drugs in and trying to self-treat their pain. So, the standard of care is, we want a long acting medication for opioid use disorder, buprenorphine and methadone to help to deal with the withdrawal symptoms and the opioid deficit. And then we want short acting opioids on top of that, along with a multimodal analgesic approach to address their acute pain. So, again, the primary challenges in dealing with a set of patients is not so much the methadone and buprenorphine itself, it's just the inherent challenges of managing patients who are already opioid tolerant, who need this analgesia. And so, when we remember that buprenorphine, it has a very high affinity to the opioid receptors, and the effect of it blocking, binding the percentage saturation on the opioid receptors and the effectiveness in blocking other opioids, it's dose related. So, doses of eight milligrams is not gonna be nearly so much of a blocking dose as doses of 16 milligrams or higher. 16 milligrams or higher are going to be, you're gonna have much more like 90 plus receptor saturation. And then, as you get down to 12 milligrams and eight milligrams, you're gonna have significantly more receptor availability to get analgesia from your other full opioid agonist binding to those receptors. And different effects that we see of buprenorphine occur at different doses for different people. And so, there's not any one dose that's going to be effective for different symptoms, but we know that buprenorphine can give us analgesia, it can give control of cravings, and control of withdrawal symptoms. The dose required for all this varies a lot between patient to patient and what their level of opioid dependence are. Some people can have control of their symptoms with a very low dose of buprenorphine, but some people need very high dose to get control of their symptoms. When we think of the antagonist effect of buprenorphine, blocking the respiratory depressant effect of opioids, it's dose dependent and it's dependent on what you're trying to block, but the higher the levels, the more effective it is at blocking from respiratory depression. But blocking, so we know that like 16 to 32 milligrams is good at blocking respiratory depressive effects of fentanyl. But just because it's raw, and also the liking effects, again, that's patient and drug specific. For some patients, the liking effects can be dropped at low doses versus high doses. But just because the studies have shown that we're going to block the respiratory depressant effects and we're going to block the liking effects, that doesn't mean that we're blocking the analgesic effects of opioids. Even though you might only have 10% of those receptors available, that can be enough to get a good analgesic effect of the opioids, even though they might not feel any euphoric effect, they might not feel any liking effect, they're not gonna, we don't have to worry that much about the depressive effect any more than we would with any other patient that we're giving them opioids in the hospital. So we can't assume just because it's blocking some effects of opioids doesn't mean that it's gonna block the analgesic effect of opioids. And when we think about which medication that we're going to use in these patients, it's important to understand what the binding affinity is of the other opioids, which is why I keep mentioning hydromorphone and fentanyl, because they are the closest, so the lower your, the lower the number on this, the higher the receptor affinity. So things like used in the operating room, like Sufentanil, super, super high, luckily that's, you know, Carfentanil, things like that, you know, nothing is gonna block those medications. But Naloxone even is difficult to reverse, buprenorphine can, but it's competitive binding. So hydromorphone and fentanyl are really, are two drugs that are gonna have the lowest, the highest binding affinity, and the best chance of being able to compete for those binding sites. And it's a competitive binding, so it's all about the concentration of the drugs in the system. So, but we're generally not gonna use medications like morphine or hydrocodone, because they're just not very good at competing with those binding sites with buprenorphine. So we know that when we stop buprenorphine, it increases mortality rate and return to use. So in general, we're not going to, we're gonna do everything we can to avoid stopping buprenorphine when people are hospitalized or having a surgery. So there have been like at least five or six different studies in meta-analysis published in the last five years that have looked at comparing patients who were told to stop their buprenorphine before their surgery versus patients who are allowed to continue their buprenorphine during surgery. Because historically, there have been a number of hospital, I mean, it's all over the place. If you look at like protocols from hospitals, someone say, stop your buprenorphine five days ahead of time. I mean, I can't imagine what misery someone's going to feel in an opioid withdrawal for five. The last thing you want, what an anesthesiologist wants is someone coming into surgery who's in florid opioid withdrawal. Like who, what kind of anesthesiologist wants that? That's just awful. So if you're, so what they found is that if you continue buprenorphine at at least moderate to low doses, so eight to 12 milligrams a day, that you have significant improvement in outcomes. You have less pain, less opioids, so you have less pain, less opioids needed, better patient satisfaction, all the outcomes are better if you continue at least a medium to low dose of buprenorphine than if you discontinue it. All these studies basically show patients with buprenorphine who is discontinued actually require more opioids in the perioperative period because you are creating that opioid deficit, a huge opioid deficit by stopping the buprenorphine. And again, you can't treat the pain until you treat the opioid deficit. So you're having to catch up with that and the more days they're off the buprenorphine, the more opioid deficit you have as it's leaving your system. So again, these, there's a lot of, there can be a lot of fear around administering high-dose opioids to these folks. One of the biggest ones is again, the stigma that they're just feigning the pain as a manipulation to obtain opioids. You know, you have to trust the patient. They're not gonna be any more likely to experience respiratory depression than any other person that you're experiencing, you know, that you're administering opioids to. I mean, that's the wonderful thing about being in the hospitals. We can monitor people, we can put a pulse ox on people or we can put, you know, cardiorespiratory monitoring and we can monitor for over sedation. So we have the ability to titrate to effect. So you titrate, don't look at the numbers of the medication because it can be scary how much medication, you know, the doses of opioids you need to give these people to get it under control sometimes. It's okay, don't even look at the numbers, look at the patient. What the patient is telling you, what the vital signs are telling you, that's what you should be using to guide your dosing, not kind of these inherent biases of the fear that you're being manipulated by this patient in some way. I can tell you the patient, like it's way easier for the patient to leave the hospital and get any drug. As soon as they leave the hospital and walk out the door, they can take as much fentanyl as they want, right? The hospital is not an easy place to get drugs, okay? It's easy to get drugs when they leave the hospital. So it's not people's goal. And generally, there's also this fear that if I give opioids to this patient, that that's gonna trigger a relapse in patients. And I'm not saying that that's never true. When you send people home with IV opioids, especially with a prescription for opioids, especially if they're off of their buprenorphine, it is a concern, you have to worry about that. But it's much more risky, the risk that untreated pain will lead to return to use is much higher and a much greater risk than the risk that giving, you know, treating the pain will cause a return to use. So it's always, you know, return to use is always something we have to consider, but remember, the biggest risk for that, untreated pain and stopping people's MOUD is what's gonna cause that generally. So our basic pain management options when we're dealing with acute pain. So for one thing, maybe it's not that bad. So someone who is having a, maybe, you know, they're having a vaginal delivery, they're having a laparoscopic cholecystectomy, they're having a hernia repair, they're having their teeth extracted, like a minor day in and out outpatient surgical procedure. Generally, it's not even really worth it to use opioids in those patients. I mean, sure, when they're there at the moment, you can give them some, but when they go home, it's probably not worth, you're not gonna have time to figure out how much they need. So generally in those patients, we just recommend increasing the dose of buprenorphine to cover their pain, especially if they're, you know, if they're only taking 16 milligrams a day, then you can give them 32, 40, you know, give them an extra eight milligrams every, you know, four times a day of buprenorphine, especially true if someone's on long-acting injectable buprenorphine. There's no issues with insurance then, you can prescribe sublingual on top of that and insurance will pay for it. So we can give them eight milligrams of buprenorphine to take four times a day on top of their normally scheduled dose of buprenorphine. And that, along with all of our other adjunctive medications can be sufficient to treat their acute pain when it's not really severe pain. When we have, when we're gonna be having an inpatient surgery or we have a major trauma, that kind of thing, then we are going to continue their buprenorphine. We can consider reducing it down to 12 milligrams or less, but it's not absolutely necessary. Like sometimes you don't have a choice. If someone's on sublucade, you're stuck with it. You can't change that. And then you're gonna use all of your multimodal analgesia and high dose potent short-acting opioid analgesics titrated to effect on top of that. And ideally, when ideally figure out what's gonna work, ideally switch them to oral before they leave the hospital, right? We try to do that with all medications before people leave the hospital, but particularly in this case, if you're treating someone with some doses of IV, like I've had patients who were in the hospital and they were given all these huge dose of IV medications, and then they were sent home with like three, five milligram percocet a day. Like, you gotta be kidding me. So finding out what works for the patient orally before you send them home is really important. And again, collaborating with that patient's buprenorphine prescriber in the outpatient setting to generally they're gonna be the patient that's gonna take over their outpatient pain management postoperatively for the next week or two after they get out of the hospital. So you need to do that, have the discharge planner collaborate with their outpatient provider. Now, the last dish effort would be discontinuing buprenorphine altogether and just giving them opioids on top of this. This is not recommended, but unfortunately this is generally patient directed. So the patient themselves is so worried because they understand that buprenorphine blocks the effects of opioids. And especially if they haven't been in this situation before like we as a doctor can tell them, hey, all of these studies show that you're actually gonna have way more pain if you stop your buprenorphine, but patients sometimes they just can't convince them sometimes. And they absolutely refuse to take their buprenorphine in the hospital. It just happens sometimes. So you just gotta roll with it. And then you just give them the amount of opioids they need. They're gonna need a lot more than if they took their buprenorphine, but you give them, same thing, you give them what they need to control their pain. And then ideally, again, we really want to get them back on their buprenorphine before they leave the hospital. And if they refuse, we really need them to understand the significant risk behind stopping their buprenorphine. So that is only kind of last dish effort when the patient refuses the standard of care. So again, other than urgent and emergent situations or patient refusals, you should not discontinue buprenorphine without talking with a specialist about doing that. Now, what doses of opioids do you need? There's very little literature on this. This is a Swedish study looking at a post-Caesarean and they were showing oral hydromorphone doses of between four to eight milligrams every four to six hours as being effective doses for the same length of time that they might treat other people who aren't on opioids. This is another, some other recommendations here from Penn Medicine. So there are, they mentioned oxycodone here. I've had a few patients that prefer that to hydromorphone, but again, it doesn't actually have as high binding affinity as hydromorphone does. So again, they're also looking at approximately eight milligram doses of hydromorphone. So those doses might seem a little scary or starting with two milligrams IV, like two to four milligrams IV. I've had patients made up to eight milligrams. Again, like these doses, just remember like, like Sublocaine for example, it is designed to block the liking effects of 18 milligrams of IM hydromorphone. Just like keep that in the back of your head when you're treating the liking effects, not the pain control, the liking effects. So just don't let these numbers scare you. Just treat the patient and give them the amount that they need and use your objective signs and patient report to guide your dosing of that medication and clearly hold or reduce for over sedation. And really maximizing those non-opioid multimodal is very, very important. And then again, making sure to try to start the methadone or buprenorphine before they leave the hospital. There's been a big push in the last five to 10 years to make sure that we are offering multimodal analgesia. It's much more effective than just giving people opioids. So, obviously when we do acetaminophen and NSAIDs, those should be scheduled, not PRN. We should schedule anyone who doesn't have contraindication to those two medications should get scheduled NSAIDs and scheduled acetaminophen. If they can't take PO, you can do IV acetaminophen. Any, if it's a neuropathic pain, using gabapentinoids for sure. If it involves an extremity, if you can have anesthesia do a local or regional block for you, that's super effective. The ketamine, again, can be very helpful for people. It both manages pain, analgesia, and it reduces opioid withdrawal symptoms. So, it has a couple of good things for people who don't have severe cardiac problems or other issues, psychosis or other issues that would be contraindications to ketamine administration. IV lidocaine is another thing that you don't hear very much about. And again, people have to have not a lot of other medical comorbidities to allow for the safe use of low-dose IV lidocaine infusions. But this study is in period operatively, and this was in major orthopedic surgery in patients who had opioid use disorder or opioid tolerant. They gave IV lidocaine infusions during their surgery, just during the surgery, not afterwards. And they had really dramatic reductions. They used only required about half of the amount of opioids and they had about like double the patient satisfaction in their level of pain control. So, if you have a relatively healthy person that could tolerate IV lidocaine, that's something to consider for these patients. So, this is some case reports, just to give you some examples of patients who are on extended-release injectable buprenorphine who had some very painful issues. So, it's three cases, if you wanna read about an ischemic limb surgery, metastatic malignancy, and a knee replacement. So, there's some of our, what we think of most painful conditions that you can have in the hospital. And all of these patients were able to achieve adequate analgesia despite the fact that they were on extended-release buprenorphine. So, if you wanna read a little bit more about that, about the cases, you can look at that article. Just at the tail end here, just talk a little bit more about trying to reduce patient-directed discharge. So, why do patient-directed discharges happen? There's lots of different reasons, but if people aren't getting adequate control of their withdrawal symptoms or their pain, also other issues, control of their anxiety, their insomnia, all of those issues that are very triggering and distressing for them, those can be reasons why people want to leave. People can feel, can have a lot of trauma associated with being in the hospital, feeling that they've lost their freedom, that they're trapped there, especially in patients that have underlying anxiety and PTSD. And the attitudes of the staff is really critically important, creating, having staff that really are still struggling with their internal biases, the difficulties in treating this patient population and just are really jaded and burnt out. You know, they can, you know, not intentionally, but can really mistreat people and create an environment where people are suffering a lot of stigma and they're not experiencing empathy. So, you know, providing the education and the resources that the staff need to understand the disease of addiction, understand a trauma-informed care approach and how creating an environment of empathy and respect and autonomy can help patients feel safe to stay in the hospital is really critical. We want to identify substance use disorders and make sure patients understand that it's safe for them to talk with their struggles with you and that you're there to help them. Starting people on methadone or buprenorphine is going to reduce AMA and really moving from this change, shifting our environment rather than us being the police and the security personnel, monitoring this person, that we are there as a partner to try to help in whatever way we can to improve their health and help them meet their goals. And it's not our job to police patients and what they're doing when they're in the hospital. Again, treating all of the underlying symptoms that may be somewhat more difficult to treat in this patient population, but it doesn't mean that we shouldn't be trying as hard as we can to relieve them. And then if we can get, if we can get like a, if there is a community support, like a care navigator or a peer support person who has lived experience, some of those organizations, if you can collaborate with them, will have peers who can actually come into the hospital and meet people while they're there. They can talk with them about ways that they can connect outpatient care. They can talk with them about, they may be more willing to talk with that person honestly than they are talking with you. So that can really help again to like improve that therapeutic alliance and improve that warm handoff to care. And they might be able to not come in personally, but they might be able to do a phone call with that patient. They may be able to text with that patient and offering harm reduction services in the hospital. So there are hospitals now that are really progressive that actually have onsite supervised consumption sites, just like, you know, we hear about the overdose, overdose prevention sites, like in New York and in San Francisco, where people are allowed to come in and, you know, use their drugs in a supervised setting. So if they, you know, they have clean, safe supplies and if they have an overdose, they're able to be resuscitated. They're dramatically effective at reducing overdose rates and improving safety. So there are actually some hospitals that have supervised use sites onsite in the hospital. So that's a trend we're seeing nationwide, but most don't, of course, and actually most of them don't have smoking availability in those, which is a barrier, but you can have supplies either that you as a hospital have to hand out, or you have maybe a peer from a harm reduction organization in the community that can come in and share harm reduction supplies with the patient. And just in general, you know, we want to, we wanna shift our discharge planning to focusing as much as we can on that warm handoff to care, starting care in the hospital and a warm handoff to the outpatient, rather than just detoxing people and then giving them a piece of paper that says this is where you can go, because that doesn't result in good outcomes. Now, again, sometimes patients are wanting to leave, regardless of our advice, they're not willing to stay in the hospital. So it's really important to remember, especially if they're in the emergency room after an overdose of how incredibly high their risk of death is in those first couple of days after the hospital. So again, risk of death in that first year is about 8% of those patients. Of those patients, 20% died in the first month, and of those that died in the first month, 22% were in the first two days after their non-fatal overdose. So it's good, you can also develop a standing order set for patients with OUD who are leaving AMA. So just because a person is leaving AMA doesn't mean that you can't give them their prescription for buprenorphine, you know, saying, I'm not gonna give you your prescription because you're not staying, so you're on your own. Like, that's not the medically, the right thing to do or the compassionate thing to do. So even if they're leaving AMA, you can still offer them to give them, you can give them an extended release of buprenorphine injection before they leave, you can give them a high dose of buprenorphine right before they leave, you can give them, even if they won't accept those, you can, maybe they're not even in withdrawal yet, you can give them at least a week prescription for outpatient buprenorphine, regardless of whether they're, they may not even know if they want an outpatient treatment, that's okay. It's better for them to have the medication, and then they have the opportunity to take it, every opportunity that they have that they take buprenorphine and have a positive experience is more likelihood that they're gonna wanna stay on it for the longterm. One more plug for this wonderful website and all the resources you can see, they have a blueprint for hospital opioid use disorder, treatments, they have things about billing in here, pharmacy frequently asked questions, just like, just tons and tons of resources on here. This is my contact information. You can feel free to reach out to me via my email or text. I work at the Nenilchik Clinic, it's the only clinic in Nenilchik, so it's not too hard to find me, so feel free. If you want more resources, you saw something you're interested in, can I get more information about that? You should have, try to make sure you guys have access to the slides. If for some reason you don't, I can give you, send you like a Google Drive link to the slides and we can, I do, you know, just kind of curbside consultations for people as needed. Sometimes when you have a complicated case, if any of you happen to also work in the tribal health system in Alaska, ANTHC is gonna be starting up its free provider consultation service for addiction medicine starting again in September. So I'm the main person providing that service. So anytime we need it, it's, you know, free consultation services, you know, because curbside kind of things. I'm not doing direct medical care, except in the, on the Homer hospital, but. Questions. Before lunch. Oh, right on time. It's 12 oh one. Perfect. I always go over. That was perfect timing. Any other? Dr. Rai, I have a question. I'm a general surgeon and I had a patient recently, it seems to be coming from the Alzheimer's level. Yes, yeah. She was on methadone for 117 milligrams. Yes, yeah. Paying for the last 12 to 15 years. Yes, yeah. Nobody else. She says, I said, have you ever tried to withdraw or decrease the total? Yes, yeah. Yeah. She says, no. I don't agree with that. I get help. Yes, yeah. Yeah. The question is, if you go to a clinic and you keep getting medication, who makes the decision, but who withdraws from the clinic? Or what do you mean? So tapering medication should always be patient-directed because it tends to always result in worse outcomes than keeping at the medication dose that works. So we as providers should never suggest the patient should reduce their dose. It should always come from the patient. Because anytime a patient reduces or stops their dose, there's going to increase risk that they're going to go back to using or die. So it's always safer to stay on the dose that works. So we don't, there are historically, there have been states and insurance companies that had mandates, like after two years, you have to try to taper down. And we found that had very poor outcomes. So the safest thing is you find the dose that works and you stay on it as long as the patient is willing to. And for the rest of their life, perfect. That's great if that's what worked for the patient. But at any time the patient wants to, they absolutely can start tapering off. And the support is always available. It's very restricted in methadone clinics. They have very specific protocols on how they do that. So it's something that is available to patients anytime they want to do it, but it should always be patient directed. And just always remember, because that is one of the common misconceptions is that these medications, after you've been on them for a while, should be tapered off. Would we suggest a diabetic taper their insulin down and try to work harder on their insulin, their exercise and say, well, you've had five years on insulin now. You should have learned how to eat right and exercise right. There's no reason why you can't. So let's taper your insulin down, right? It's exactly the same. This is a chronic disease. It doesn't go away. People generally, especially with severe disease, people usually probably need treatment for a very long time, possibly for the rest of their lives. And that is perfectly fine. Oh, do you recommend switching from methadone to buprenorphine? So it does happen sometimes. So I think whatever's working for you, if it's working well and you like it, and it fits into your lifestyle and all that, then stick with what's working well. But there are, methadone has many, many barriers that make it very difficult to access. So first of all, you have to live in that city, right? So if you move, so this lady who moved from California to Homer, Alaska, there was no option. She had to switch. People get a job sometimes. Like you have to go to the methadone clinic every day. That's incredibly disruptive to your daily routine. And when you want to have a job, especially if you have shift work that changes shift, you know, and you could lose your job if you have to go to the methadone clinic every day. Some people, they just, they get sick of the hassle. They just hate, you know, it's just too much work to go to the methadone clinic every day. So they might decide to switch for that reason. You know, methadone in general tends to be somewhat more effective than buprenorphine. It has a higher retention and treatment than buprenorphine does, but it's also a little bit more risky of a medication. It also doesn't block opioids as well as buprenorphine does, but it provides a much higher opioid agonist effect so you can get better pain control and that kind of thing. So again, it's really patient directed, but the biggest thing we see with methadone clinics, people, the reason people want to switch from methadone to buprenorphine is either because they lose access because they're moving someplace where they don't have it, or they're getting their lifestyles changed in a way that no longer allows them to go every day, or they, it just hasn't worked for them because it's too much work. Like they just, they can't, it's an incredible, can you imagine if every day you had to take two hours out of your day every day, traveling sometimes an hour, half an hour, spending hours at the clinic every single day? Can you imagine how disruptive that is to your life and how hard it is to rebuild your life into a normal life again when you have to do that every day for years? So there are patients that just get sick of that, or they just can't do it. Like they're homeless, they don't have transportation, they can't do it. Maybe they need it very much, but they can't stick with it. And so those are situations in which, even though ideally it would be a great medication for them and ideally it would work well if they could access it easily, they don't really have a choice. And so their buprenorphine is kind of their second line of choice. And a lot of those patients too, when they've struggled, if they are, if it's because they're struggling, like they're struggling to take their medications every day, they're struggling to go to their appointments, those may be patients that we really recommend getting them on long-acting injectable buprenorphine because it takes that work out of it. You don't have to remember to take a medication every day. You can get really high medication levels. It's easy to access. You have a lot of flexibility in your appointments. So yeah, those are the most common reasons that people would make that switch over. Thank you. Do you see any changes in the regulations on methadone? Yeah, they're coming up. So a couple of things just changed last month. So one was actually I think last week or two, they just took effect. So one is they made permanent some of the telemedicine flexibilities so that they still at some point do need to have an in-person visit, but they can do at least some of their care over telemedicine. They also allowed the increased flexibility with take-home doses, which is provider and kind of clinic directed, which is great. So it allows the prescriber the ability based on the person's situation to decide at what point and they are safe to have take-home doses and for how long versus it used to be, you have to go to a methadone clinic every single day for an entire year before you could get a single take-home dose. And then you can only get a week at a time. You had to go for two years before you could get like two weeks or more of take-home doses. So that has changed. And they showed very good outcomes during COVID when they allowed a lot of take-home doses that nothing bad happened. We thought bad things would happen, but actually nothing bad happened. Everything was fine. So that is actually still allowed. So it's provider specific and patient specific on what is appropriate and safe for that patient, but they are able to, which is why this patient who was coming up to California to see me, she had only been in the methadone clinic for six months and she delivered her baby, but she was able to get two weeks of take-home doses when she left, which has never happened in the past. So there is a bill called the Modem, the Modernization of Opioid Treatment Act that is in Congress right now that is going to allow for outpatient prescribing of methadone to be dispensed at local pharmacies by addiction medicine specialists only. So that is, it's in progress. It's promising that it might pass, but you know, like with the election year and all that, not, no, it's just happening. So, but there is a huge push and there was a huge push at the national conference, really a lot of people talking about this, about the, that it's, we need to, this medication is incredibly difficult to access and, you know, like we need to make it, we know it's an effective medication. We know that it can be used safely, you know, with this COVID experience with much less regulation. And so there's a huge push to make it more available, but it's not, not yet. Would we be able to see it on the PDMP as part of that new legislation? You cannot see it on PDMP. If with the new legislation. Yeah, so if it was, yes, if it was sent from a local pharmacy, assuming unless they changed something about that, but like you can see the buprenorphine ones on the PDMP. So that's kind of where the weird privacy thing, we're like, we're protecting our CFR 42 part two. So if the emergency room calls me, unless the patient's dying, I can't actually tell them that they're my patient, but at the same time they can see on the PDMP that they're my patient because I'm prescribing buprenorphine. So like OTPs, the methadone clinics do not report on the PD, although they are allowed to now, since the rules change, they're allowed to, but they don't. But yeah, if that changes, then we would be able to see the methadone on the PDMP. With you being on the peninsula, I mean, you know from here that you're gonna be doing, or someone is gonna be needing an elective knee replacement. Can you ever refer them to the anesthesia department at Central Peninsula Hospital to have like a pre-op visit and discuss their concerns about maintaining or is that ever being done? I mean, I think that's a great idea. I don't think it's happening very often that people are having those pre-op consultations with anesthesia, but I think it's a great idea for that to happen. I definitely have like a form letter that I write out for patients that explains like the recommended protocols for them to give their surgeon or the anesthesiologist. But yeah, I think that's something that probably should happen a lot more than it's happening right now is that pre-planning ahead with the anesthesiologist and the surgeon about what the management's gonna be during the hospitalization for those major surgeries. Yeah, it's a great idea. Yeah. I had a patient who had been on suboxone but had self-tapered, had run out of opioids, got admitted for a separate painful condition. Previous provider gave her nothing the first day or two and I didn't actually know about the buprenorphine. I just started seeing relief with opioids. He actually was a lot more comfortable. Yeah. And then when I talked with her provider, he said, oh, get her back on her buprenorphine. Oh, did I do that? And yeah, it was before our ability to actually prescribe without the waiver. And so I didn't because of that. I was like, what's the point to have just one or two doses? But in hindsight, maybe I should have started her on the buprenorphine before even in conjunction with. Yeah, I mean, ideally, if you know the history when the patient comes in, and checking the PDMP can be really helpful for that, which we don't always think to do when a patient's in the emergency room. Until we're discharging them, I've had patients that came in, had a major MVA, her back was broken, she was in the hospital for two weeks, and I didn't get the call until the day she's getting ready to leave, when of course then they're writing the outpatient prescription, and they're like, why is it so hard to control this person's pain? And the outpatient, and then they're like, oh my gosh, and then I get the call from the hospital of, oh, we've had your patient here for the last two weeks. So I highly recommend, there's great things about checking PDMPs on patients even before you need to do that, just to get the history, because patients are afraid. They're very, she was terrified to tell them, because she assumed, like, if I tell them that I'm on buprenorphine, I have OED, they're not gonna give me pain control, they're not gonna give me opioids, but patients don't wanna tell you because they're very scared, because of the trauma they've experienced in the past. But yeah, ideally, if you knew, it would be great to do both at the same time, or if you needed to, you could start the other opioids first and then start the buprenorphine a couple days later with one of these overlapping start kind of things, or in the worst case scenario, you can give them a prescription and start as an outpatient. Methadone, although you can't prescribe, you cannot prescribe, I forgot to mention that, although you cannot prescribe methadone outpatient, like this guy, the guy that, in the case, he was given a one-week prescription of methadone as an outpatient for pain. So you write for pain on it. That technically is legal. It's a very legal shady ground, because he also has OED and you're actually really prescribing it for the OED, maybe for the pain too. So it's actually not legal to give someone a prescription when they leave the hospital for methadone to treat their OED until they get to the methadone clinic. It is now, they changed the law now though, that it is legal to dispense three days of methadone. They just changed it last year. So it's legal to dispense, not prescribe, it has to be dispensed from the hospital or the emergency room three days of whatever dose of methadone they need to bridge them to, to get to the methadone clinic. Any questions? I'll be here during lunch. So feel free to chat a little bit. And what time, Jan, what time are we restarting? Do we have an hour off for lunch or what time? Yeah, I'll jump in here. Thank you so much, Dr. Spencer. That was an outstanding morning. Thank you.

opioid use disorder

hospital settings

opioid withdrawal

opioid agonists

acute pain management

buprenorphine

transitions of care

medication-assisted treatment

readmission rates

mortality risk

emergency departments

EMTs

precipitated withdrawal