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Review
April29, 2024
HonoraEnglander,MD1; Ashish P.Thakrar,MD, MS2; Sarah M.Bagley,MD, MSc3; et al TheresaRolley4; KathrynDong,MD, MSc5; ElaineHyshka,PhD6
Author Affiliations Article Information
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1Section of Addiction Medicine in General Internal Medicine and the Division of Hospital Medicine, Department of Medicine, Oregon Health and Science University, Portland
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2Division of General Internal Medicine, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia
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3Section of General Internal Medicine, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts
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4Boston Medical Center, Boston, Massachusetts
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5Department of Emergency Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
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6School of Public Health, University of Alberta, Edmonton, Alberta, Canada
JAMA Intern Med. Published online April 29, 2024. doi:10.1001/jamainternmed.2023.7282
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Abstract
Importance The rise of fentanyl and other high-potency synthetic opioids across US and Canada has been associated with increasing hospitalizations and unprecedented overdose deaths. Hospitalization is a critical touchpoint to engage patients and offer life-saving opioid use disorder (OUD) care when admitted for OUD or other medical conditions.
Observations Clinical best practices include managing acute withdrawal and pain, initiating medication for OUD, integrating harm reduction principles and practices, addressing in-hospital substance use, and supporting hospital-to-community care transitions. Fentanyl complicates hospital OUD care. Fentanyl’s high potency intensifies pain, withdrawal, and cravings and increases the risk for overdose and other harms. Fentanyl’s unique pharmacology has rendered traditional techniques for managing opioid withdrawal and initiating buprenorphine and methadone inadequate for some patients, necessitating novel strategies. Further, co-use of opioids with stimulants drugs is common, and the opioid supply is unpredictable and can be contaminated with benzodiazepines, xylazine, and other substances. To address these challenges, clinicians are increasingly relying on emerging practices, such as low-dose buprenorphine initiation with opioid continuation, rapid methadone titration, and the use of alternative opioid agonists. Hospitals must also reconsider conventional approaches to in-hospital substance use and expand clinicians’ understanding and embrace of harm reduction, which is a philosophy and set of practical strategies that supports people who use drugs to be safer and healthier without judgment, coercion, or discrimination. Hospital-to-community care transitions should ensure uninterrupted access to OUD care after discharge, which requires special consideration and coordination. Finally, improving hospital-based addiction care requires dedicated infrastructure and expertise. Preparing hospitals across the US and Canada to deliver OUD best practices requires investments in clinical champions, staff education, leadership commitment, community partnerships, quality metrics, and financing.
Conclusions and Relevance The findings of this review indicate that fentanyl creates increased urgency and new challenges for hospital OUD care. Hospital clinicians and systems have a central role in addressing the current drug crisis.
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Citation
Englander H, Thakrar AP, Bagley SM, Rolley T, Dong K, Hyshka E. Caring for Hospitalized Adults With Opioid Use Disorder in the Era of Fentanyl: A Review. JAMA Intern Med. Published online April 29, 2024. doi:10.1001/jamainternmed.2023.7282
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