By Jill Pease
As opioid use has shifted to fentanyl and other high-potency synthetic drugs, treatment guidelines need to keep pace to reduce overdose deaths. A new article published in JAMA Network Open highlights hospitalization as an opportunity to begin treatment in patients with opioid addiction and offers best practices for hospital clinicians.
The new guidelines are based on consensus from dozens of national experts who treat people with opioid use disorder.
“New high-potency synthetic opioids are very inexpensive to produce and even trace amounts are dangerous,” said Jamie Pomeranz, Ph.D., a clinical professor of occupational therapy at the University of Florida College of Public Health and Health Professions, who served as a co-author of the new study along with colleagues at Yale University, Harvard University and the University of Pittsburgh.
“In this new phase of the opioid crisis, manufacturers are producing more of these drugs, people are taking higher doses and other substances are being laced with fentanyl and other opioids,” said Pomeranz, also the college’s associate dean for undergraduate programs.
As a result, the risk of overdoses becomes significantly higher, he added.
The study’s authors used a Delphi method to build consensus among 42 clinicians, many of whom are board certified in addiction medicine and/or addiction psychiatry. The multi-round survey process involved asking participants a series of questions about treatment practices, based on hypothetical patient scenarios. Next, everyone’s anonymous responses were shared with the full group and participants were asked to evaluate all responses as the group moved toward consensus.
“With the Delphi process, you avoid the problem with focus groups where participants could be influenced by people in the room,” said Pomeranz, who served as the study’s Delphi consultant. “It allows participants to consider what everybody is thinking about an issue, but also consider your own point of view. It is also an accessible method to involve people who are very, very busy.”
At the conclusion of the process, participating experts agreed on the importance of starting medications for opioid use disorder among hospitalized patients, rather than waiting until patients are discharged. They also arrived at best practices for several treatment protocols involving methadone and buprenorphine, two medications prescribed to treat opioid use disorder. These medications have been shown to reduce the risk of overdose and death by 50%.
“We hope this consensus-backed guidance can help improve medications for opioid use disorder initiation practices in the hospital and highlight areas where more research is needed to clarify the benefits of certain adaptive practices,” said the study’s lead author Shawn Cohen, M.D., an addiction medicine specialist and assistant professor of medicine at Yale University in a news release. “As the drug supply continues to change, such as with the recent emergence of newer adulterants like medetomidine, people who use drugs are feeling the brunt of the impact. We need to continue to find ways to adapt our care rapidly using the best evidence and knowledge we can.”
The study results not only provide important guidance for clinicians, they can serve as a reference for family members or case managers who are advocating on behalf of a patient with an opioid use disorder, Pomeranz said.
While more robust research is needed to evaluate treatment efficacy of different medication initiation strategies, the study demonstrates the value of bringing experts together to identify emerging best practices. As healthcare providers adapt to a rapidly changing drug use landscape, researchers hope these recommendations will help create a more consistent continuum of care that begins in the hospital and extends beyond discharge, giving patients a stronger foundation for recovery.
There is a misconception that opioid use disorders affect only people within certain demographic groups, but the problem is becoming far more widespread, Pomeranz said.
“As high-potency synthetic drugs become more available, we cannot pretend that addiction is not happening in our own backyard,” Pomeranz said. “It will likely affect someone you know and it’s something we should all be concerned about.”