Medication for Opioid Use Disorder (MOUD) in the Hospital
What licensing do I need to prescribe buprenorphine or methadone for an inpatient, either as a new start or as an initiation?
No additional licensing is required to prescribe buprenorphine or methadone for patients in the hospital who are admitted with a primary medical problem other than opioid dependency. This is true even for patients who have not previously started to take buprenorphine or methadone. An X (Data 2000) waiver is required for discharge prescriptions, therefore it is recommended to have at least one provider who is X waivered. See appendix for full regulations.
What if the patient does not have a primary medical problem separate from opioid dependency or is not admitted?
Even in cases where a patient does not have a primary medical problem, buprenorphine or methadone may be administered for up to 72 hours. Most often, this comes up when a patient presents to the ED in withdrawal but does not need admission, or when an admitted patient has been discharged and has a short wait before they can be seen in an outpatient clinic. Buprenorphine or methadone can be administered without registration as a narcotic treatment program under Title 21, Code of Federal Regulations, Part 1306.07(b), provided:
Not more than one day’s medication may be administered or given to a patient at one time
Treatment may not be carried out for more than 72 hours
The 72-hour period cannot be renewed or extended
This is generally done with the intent to bridge a patient until they can connect with ongoing treatment, often in an ED or bridge clinic setting. Of note, medications need to be administered i.e. dosed on site, not prescribed. Patients should not be admitted to the hospital solely for this purpose. After the 72-hours, the patient will need to receive methadone or buprenorphine from a opioid treatment program (OTP). Alternatively, prescribers with a DATA 2000 waiver are able to prescribe buprenorphine for the treatment of opioid use disorder outside on an OTP.
I want to continue methadone for a patient stabilized on an outpatient dose, what steps should I take?
It is recommended to continue a patient’s methadone therapy during their inpatient hospitalization whenever possible. The last dose amount and date should be confirmed with the patient’s opioid treatment program upon admission.
What if I cannot confirm a patient’s outpatient methadone dose?
If a patient has evidence of opioid use disorder, and presents with opioid withdrawal symptoms, but their outpatient methadone clinic cannot be reached to confirm a dose, they should be treated as a new methadone start. Give methadone per the guidelines, and call the methadone clinic as early as possible to confirm date and amount of their last dose.
I want to continue buprenorphine for a patient stabilized on an outpatient dose, what steps should I take?
A call to the patient’s pharmacy can help confirm that a patient is prescribed buprenorphine and at what dose. Additionally, buprenorphine prescriptions are transmitted to CURES, California’s prescription drug monitoring program, and dose and quantity prescribed can be found at https://cures.doj.ca.gov. Please also confirm with the patient directly that they have been taking it as prescribed. If they have not been consistently taking the medication and have used other opioids, restarting the medication without treating it as a new induction increases the risk of precipitated withdrawal.
What if the patient has pain or will have surgery?
Continue their outpatient dose! Home buprenorphine or methadone can be split BID or TID to improve pain control, and additional non-opioid and opioid analgesics should be used. Buprenorphine and methadone will not prevent opioid analgesia from being effective. If the patient is on a stable dose of buprenorphine, receiving additional opioids will not put them at risk for precipitated withdrawal. See our perioperative and acute pain guidelines for further details.
My patient has renal impairment, can I continue/start buprenorphine, buprenorphine/naloxone or methadone?
Yes, neither buprenorphine, naloxone nor methadone are renally cleared to a clinically significant degree.
My patient has hepatic impairment, can I continue/start buprenorphine, buprenorphine/naloxone or methadone?
Both buprenorphine and naloxone are hepatically metabolized. Moderate and severe hepatic impairment prolong the half-lives of both buprenorphine and naloxone. If the combination product is used, however, the half-life of naloxone is prolonged to a greater degree than buprenorphine, which may rarely lead to accumulation and precipitated withdrawal. It is not recommended to use the combination product in severe hepatic impairment, and it should be used cautiously in moderate hepatic impairment. A buprenorphine solo product may be used cautiously in patients with hepatic impairment--generally however it is avoided if AST or ALT is > 5x the upper limit of normal.
The manufacturer of methadone does not provide guidance on dose adjustment in liver impairment. However, because methadone is metabolized by the liver, the half-life may be prolonged in moderate to severe liver impairment and dose reductions may be required.
What is the risk of precipitated withdrawal with buprenorphine initiations?
One of the primary concerns with initiating buprenorphine is precipitated withdrawal in patients who are currently tolerant to a full opioid agonist. This risk is mitigated with assessing recent opioid use and ensuring the patient is experiencing mild to moderate opioid withdrawal symptoms at the time of treatment (COWS ≥ 8 with some objective signs). Risk is highest if the patient is transitioning from methadone to buprenorphine. If a patient was recently hospitalized, incarcerated, or otherwise not using opioids for >7 days, but does have documented opioid use disorder, they may safely be started without risk of precipitated withdrawal.
A careful conversation with the patient about the risk of precipitated withdrawal may be necessary. If the patient is not currently in opioid withdrawal but is interested in medication-assisted treatment, referral to outpatient treatment with or without a prescription are still appropriate. One retrospective evaluation of buprenorphine initiated in a single ED reported no instances of precipitated withdrawal in 158 cases of initiation. Notably, this study included only patients who presented in active withdrawal.
If my patient is on buprenorphine, will opioid analgesics cause withdrawal or be ineffective for pain?
Although this is a common concern among patients on buprenorphine therapy, if a patient is currently taking buprenorphine, addition of a full opioid agonist does not precipitate withdrawal. Precipitated withdrawal only occurs in patients physically dependent on a full opioid agonist is given a partial opioid agonist or opioid antagonist. Once a patient has been taking buprenorphine, they may add opioid agonists without risking precipitated withdrawal with their next dose of buprenorphine. Given a patients opioid tolerance they may need higher doses of opioid analgesics than non dependent patients, but opioid analgesics should be effective.
How long do I need to observe a patient prior to discharge after a dose of buprenorphine?
Multiple studies have confirmed the safety and efficacy of home buprenorphine induction without direct observation. Low doses of buprenorphine should not cause respiratory depression in patients with known opioid tolerance. Monitoring following dosing inpatient or in the emergency department is only necessary for ensuring that the dose improved withdrawal, for about 1 hour.