The following is adapted from actual patient encounters, illustrating complicated hospital dispositions for some patients maintained on methadone for opioid use disorder (OUD).
It’s a spring Friday in Denver, Colorado. Despite flowers blooming a week ago, it snowed an arresting eight inches last night. I trudge my way into Denver Health Medical Center, the city’s storied safety-net hospital, and turn on the pagers for addiction medicine consults. We have a physician-led addiction medicine team, providing specialty addiction care1 to the numerous hospitalized patients suffering from substance use disorders. Our census today—a combination of new evaluations and potential follow-ups—is 46, although in the past it has been up to 65. We do not have the capacity to offer weekend coverage, so many disposition issues need to be resolved today.
Ms. G, pregnant and in police custody, is located in the correctional care medical facility (CCMF) at our hospital. She has been using fentanyl, benzodiazepines, and stimulants off and on for years and desires help with cessation. Yesterday, I started her on methadone, but this is a calculated logistical risk. While our hospital’s opioid treatment program (OTP) has received a waiver to deliver methadone to the city jail and continue an individual’s treatment after release, that is not the case in every county. Unfortunately, Ms. G also has charges in an adjacent county, where methadone is frustratingly not available.
Why not avoid this risk and use buprenorphine instead? Ms. G’s last use of fentanyl had been only six hours prior to our initial visit yesterday and she was experiencing withdrawal. Fentanyl is short-acting, but confers a high risk of precipitated withdrawal in buprenorphine inductions.2 This is likely related to fentanyl’s lipophilicity,3 as chronic use may result in high amounts stored in adipose cells that continuously leak out into the blood stream for days. Ms. G has, in fact, experienced precipitated withdrawal multiple times in the past, even after 24 hours of opioid abstinence. Today, her withdrawal is moderately improved, but her methadone disposition remains unresolved.
My pager chirps. Mr. T came in with an intracranial hemorrhage after falling off a bicycle. He is currently connected with a local OTP (not ours) and is maintained on methadone 30mg daily. A surgical resident lets me know that Mr. T may be discharged next week. The patient is planning to move to Louisiana and live with his parents. I worry about how he will receive his methadone, where he will receive it, and whether his care can be coordinated across state lines. I propose an idea to the patient: “You may have more flexibility in the upcoming move if we get you transitioned to buprenorphine instead of methadone.” He listens, intrigued. Buprenorphine, unlike methadone, can be prescribed for opioid use disorder from our discharge pharmacy as a bridge to his eventual follow-up. After further discussion, we agree to begin a microdosing induction of buprenorphine, sparing him the uncomfortable period of opioid withdrawal required in a conventional induction. Microdosing involves using small, escalating doses of buprenorphine in combination with his full-agonist opioid (methadone) to avoid significant, abrupt displacement at the mu opioid receptors.5 I pull up the order-set and hit sign. Methadone disposition: resolved for now.
While evaluating Mr. T, I also noticed Mr. P—another consult patient—roaming gingerly down the hallway. He’s all set to be discharged, departing for a city three hours south—bus arrangements are finalized—and continue his methadone at a clinic there. But then, a sudden realization hits me: his clinic may not be open on weekends. I call the clinic and the staff inform me that their clinic will indeed be closed tomorrow (Saturday). They suggest that he present to the emergency room for temporary doses of methadone, but it’s hit-or-miss, depending on what hospital in that city he shows up to. This type of emergency dosing is legal4 but not universally offered. What would not be compliant with regulations is sending him out with a two-day methadone prescription from our discharge pharmacy. I ask if his OTP can request guest-doses at our OTP, which they seem hesitant about. They ask that written documentation of his dosing in the hospital, with my signature, be faxed over. I type a brief letter, print it out, sign it, fax it, wait. They subsequently need to get in touch with our clinic—which closes soon—stat! Methadone disposition: unresolved.
I receive a computer message from the nurse in the CCMF. Ms. G is being released from custody! Beyond the basic liberties again afforded her, she can now remain on methadone maintenance therapy, which in my opinion will give her the best shot at avoiding withdrawal, entering recovery, and maintaining custody of her future child. I breathe a sigh of relief. Methadone disposition: resolved.
I call our OTP with some apprehension for an update on Mr. P. “Did his methadone clinic follow through with requesting guest doses for the weekend in time?” My colleague tells me it’s all set up. He can discharge and pick up his weekend guest doses. Methadone disposition: resolved.
Now late Friday afternoon, I receive an urgent page from the OB/GYN service. Ms. L is in our obstetrics triage clinic, 30 weeks pregnant, experiencing opioid withdrawal. I rush down to see her. She was prescribed buprenorphine multiple times during her pregnancy, but it never felt like it was “enough” to curb her cravings. I suspect it’s time to offer methadone, which can be titrated much higher than buprenorphine. I ask the team to admit her so we can work on dose titration quickly and get her connected with our OTP on Monday. “So, we can’t discharge her after dosing her?” they clarify. The team could technically do that, but our OTP and the state’s central registry (a database of OTP patients that must be reviewed to prevent dosing at multiple locations) are now closed. Ms. L would not be able to dose over the weekend unless she presented to the emergency department each day for a sub-therapeutic dose. I relay that to the obstetricians, thankfully amenable. Methadone disposition: resolved.
I leave the hospital, satisfied and bewildered. The snow has melted, but the Denver forecast is nothing if not erratic. Birds are singing. “Or wait, is that…” I think reflexively.
Acknowledgments: The author would like to thank Dayan Colon-Sanchez for assistance with the essay.
- Trowbridge P, Weinstein ZM, Kerensky T, et al. Addiction consultation services: Linking hospitalized patients to outpatient addiction treatment. J Subst Abuse Treat. 2017;79:1-5.
- Bisaga A. What should clinicians do as fentanyl replaces heroin? Addiction. 2019;114(5):782-783.
- Schug SA, Ting S. Fentanyl formulations in the management of pain: An update. Drugs. 2017;77(7):747-763.
- United States Government Accountability Office (GAO). Opioid addiction: Laws, regulations, and other factors can affect medication-assisted treatment access. Report to the Majority Leader, U.S. Senate. https://www.gao.gov/assets/gao-16-833.pdf. Published September 2016. Accessed July 15, 2021.
- Terasaki D, Smith C, Calcaterra SL. Transitioning hospitalized patients with opioid use disorder from methadone to buprenorphine without a period of opioid abstinence using a microdosing protocol. Pharmacotherapy. 2019 Oct;39(10):1023-1029. doi: 10.1002/phar.2313. Epub 2019 Aug 15.
Clinical Practice, Hospital-based Medicine, Medical Education, Medical Ethics, SGIM, Vulnerable Populations
Dr. Terasaki (firstname.lastname@example.org) is an internist and addiction specialist practicing at Denver Health Medical Center and has an academic appointment in the Department of Medicine at the University of Colorado School of Medicine.
Introduction Neuromyelitis optica spectrum disorder (NMOSD) is a rare, inflammatory disorder of…
The Society of General Internal Medicine (SGIM) is pleased to announce its…