NURSING RESOURCE Quick Reference

CA Bridge is working to ensure that all people with substance use disorder (SUD) receive 24/7 access to high-quality care in every ​ California health system. Despite strong evidence for buprenorphine initiation in acute care, many hospitals do not offer this service. We seek to fully integrate this treatment into standard medical practice — increasing access to save lives.

The CA Bridge model is based on three pillars:

1. TREATMENT: Provide quick start, low-barrier access to evidence-based medication for addiction treatment for ​ substance use disorder in all hospital departments.

2. CULTURE: Create a welcoming, non-stigmatizing hospital culture for people who use drugs that is reflected in ​ patient-facing communications throughout the hospital and an emphasis on human connections that build trust.

3. CONNECTION: Establish pathways to link patients to outpatient care through active support and follow-up. We ​ actively promote our services to patients through community outreach.

As nurses, we need to create a culture of care that creates safety for self disclosure of SUD. We can do this by utilizing language and behavior that is not stigmatizing, but recognizes the person first rather than the disease. It is vital to be aware of our own ​ ​ perceptions and biases in order to intentionally reduce stigma and prioritize excellent patient care. ​ ​ Acute Opioid Withdrawal Opioid use disorder (OUD) is the chronic use of opioids that causes clinically significant distress or impairment and consists of an overwhelming desire to use opioids, increased opioid tolerance, and withdrawal when discontinued. The pattern is similar to other chronic conditions in that signs and symptoms can be severe, and long-term adherence to treatment is often intermittent.1 ​ There are a variety of symptoms – physical, emotional, mental – experienced by opioid dependent patients when they stop using opioids. These are outlined below; however, the most accurate assessment of the severity of withdrawal is the patient's ​ self-report. ​

SIGNS & SYMPTOMS OF OPIOID WITHDRAWAL

Objective Signs: Subjective Symptoms: ● Tachycardia ● Rhinorrhea or lacrimation Patient reports feeling "bad" ● Achy bones/joints ● Diaphoresis ● Vomiting, Diarrhea due to: ● Restlessness ● Restlessness and/or ● Yawning ● Nausea ● Hot and cold agitation ● Piloerection (“goose flesh” or ● Stomach/abdominal cramps ● Runny nose ● Dilated pupils “goose bumps”) ● Body aches

Onset of Withdrawal Symptoms: Precipitated Withdrawal: > 12 hours after short acting opioid (some may experience ● Sudden onset of severe opioid withdrawal after the ​ symptoms as early as 8 hours after use) administration of a medication that displaces opioids from > 24 hours after long acting opioid the mu receptor (e.g. naloxone or buprenorphine) ​ > 48 hours (can be > 72 hours) after methadone ● Usually time-limited and resolves with supportive care ​

NURSING RESOURCE: Quick Reference, January 2021 More resources available www.CABridge.org 1 ​ ​

Treatment Medication for Addiction Treatment (MAT) is treatment for OUD with medications to prevent withdrawal, help control cravings, ​ 2,3,4 and increase compliance with treatment which reduces mortality. ​ Treatment should be focused on low barrier, safe, and effective ​ care. Best practice treatment for OUD during pregnancy is with MAT (buprenorphine [bup] or methadone are both safe options).5 ​ Buprenorphine is a long-acting partial opioid agonist that is primarily used to treat acute opioid use disorder and withdrawal, and ​ can also be effectively used to manage pain. Bup treats cravings and physical withdrawal, but has a ceiling effect on respiratory ​ depression. It does not create significant euphoria, and helps to prevent overdose if a person uses opioids because of its high ​ ​ ​ affinity for opioid receptors. It is formulated as a monoproduct (bup alone) or in combination with naloxone. The naloxone ​ ​ ​ component functions as a deterrent that is inert when the tablet is taken sublingually but becomes active if the tablet is injected or snorted.

Quick Start Basics: Nursing Considerations: ● Verify patient is in withdrawal (if not, wait) ● Ensure bup is dissolved SL and NOT swallowed ​ ​ ● Administer bup 8mg SL (onset = 15 min, peak = 1 hr) ○ Swallowing affects efficacy and may cause ● Wait about 1 hr - assess if symptoms have improved nausea ○ Opportunity to stop and consider differential diagnosis ● Bup or bup/naloxone SL films/tablets are okay > Mimicking condition? Incompletely treated ● Alert provider for recent methadone use withdrawal? Precipitated withdrawal? ● Benzo/alcohol use are NOT treatment ● If improved, administer another 8mg dose contraindications ○ Higher dose lasts longer (goal is Q day dosing) ● Consider split dosing (TID/QID) for chronic pain ● Maintenance treatment = 16mg/day (range 16-32mg)

6 Adverse Reactions include: sedation, dizziness, headache, insomnia, diaphoresis, nausea, vomiting, abdominal pain, constipation. ​ ​

◉ TIPS: Treatment Essentials

● Treatment is most effective when provided rapidly at the time when the patient is seeking care. ​ ● It is always better to treat even when you can not ensure it will be continued or when the patient has not continued treatment ​ ​ in the past (the patient is safer while on buprenorphine for however long that is). ○ Each positive treatment experience supports a patient’s understanding that OUD is a treatable medical condition. ​ ​ ● Drug/alcohol tests may be used to inform care when appropriate, but should NOT prevent patients from starting treatment.

● Signs offering treatment or asking if people want help with their substance use invites patients to speak openly about SUD.

Discharge Planning is Key! ● Connect patient with Substance Use Navigator (SUN) in order to support engagement in care and follow-up ● Ensure patient receives naloxone in hand or as a prescription ● Facilitate follow-up care arrangements ● Educate on medication and safe storage (out of sight/out of reach or children) ● Provide hotline information (crisis and/or suicide)

References 1 ​ Dydyk AM, Jain NK, Gupta M. Opioid Use Disorder. StatPearls [Internet]. https://www.ncbi.nlm.nih.gov/books/NBK553166/. Updated June 22, 2020. Accessed October 14, 2020. 2 L​ iebschutz JM, Crooks D, Herman D, et al. Buprenorphine treatment for hospitalized, opioid-dependent patients: a randomized clinical trial. JAMA Intern Med. 2014 Aug;174(8): 1369-1376. ​ ​ ​ ​ doi:10.1001/jamainternmed.2014.2556. 3 W​ akeman SE, Larochelle MR, Ameli O, et al. Comparative effectiveness of different treatment pathways for opioid use disorder. JAMA. 2020;3(2): e1920622. doi: ​ ​ ​ ​ 10.1001/jamanetworkopen.2019.20622. 4 ​ D’Onofrio G, Chawarski MC, O’Connor PG, et al. Emergency department-initiated buprenorphine for opioid dependence with continuation in primary care: outcomes during and after ​ ​ intervention. J Gen Intern Med. 2017 Jun;32(6): 660-666. doi: 10.1007/s11606-017-3993-2. 5 ​ ​ ​ ​ C​ ommittee on Obstetric Practice. Committee Opinion No. 711: Opioid Use and Opioid Use Disorder in Pregnancy. Obstet Gynecol. 2017;130(2): e81-e94. doi: ​ ​ ​ ​ ​ ​ 10.1097/AOG.0000000000002235. 6 ​ ​ ​ Buprenorphine. In: Lexi-Drugs Online. Riverwoods, IL: Wolters Kluwer Health, Inc. https://online.lexi.com/. Updated October 14, 2020. Accessed September 24, 2020. ​ ​ ​ ​ CA Bridge is a program of the Public Health Institute. The Public Health Institute promotes health, well-being and quality of life for people throughout California, across the nation, and around the world. © 2021, California Department of Health Care Services. NURSING RESOURCE: Quick Reference, January 2021 More resources available www.CABridge.org 2 ​ ​