The “What I Wish I Knew” series of articles is a service of CPNP’s Resident and New Practitioner Committee. Articles are intended to provide advice from experts for students, residents, and new practitioners. Articles are not intended to provide in-depth disease state or pharmacotherapy information nor replace any peer-reviewed educational materials. We hope you benefit from this “field guide” discussing approaches to unique problems and situations.
Sadie Roestenburg, PharmD, BCPP
Clinical Pharmacist Practitioner
George E. Wahlen Department of Veterans Affairs Medical Center
Salt Lake City, Utah
Dr. Roestenburg, PharmD, is a clinical pharmacist at the Salt Lake City Veterans Affairs Medical Center. She works with an interdisciplinary team on the inpatient Substance Abuse Residential Rehabilitation Program unit (SARRTP). She graduated from the University of Montana Skaggs School of Pharmacy in Missoula, Montana, and then went on to complete a PGY1 pharmacy residency with Intermountain Healthcare at Utah Valley Regional Medical Center.. Her PGY2 psychiatric pharmacy residency was completed in 2015 at the George E. Wahlen Department of Veterans Affairs Medical Center.
1. What is the most common myth/misconception about managing medications for alcohol use disorder (MAUD) and medications for opioid use disorder (MOUD) inpatient?
- A common misconception from providers in various inpatient settings is that patients taking opioid replacement therapy (such as buprenorphine/naloxone (Suboxone®) or methadone) must first withdraw from these opioid medications prior to receiving treatment for other medical conditions, or that the patient is adequately covered for pain control with the Suboxone® or methadone. The patient may go through unnecessary discomfort and may be undertreated for pain due to these misconceptions. Generally, it is appropriate to continue MOUD during inpatient admissions and to consult with health psychiatry or addiction team or other resources to help appropriately manage the specific medical conditions, pain management, and addiction.
- Another common misconception is that using buprenorphine/naloxone (Suboxone®) for opioid use disorder is replacing one addiction for another. By utilizing opioid replacement therapy, it can help reduce opioid cravings and withdrawal, which can help free the patient from the preoccupation of obtaining illicit substances and can enable the patient to effectively work on the psychosocial aspects of addiction. Some patients stay on these medications for short term, but some stay on them long term depending on what the individualized goals are for each patient (staying out of jail, obtaining a job, etc.).
- In regards to MAUD, there are times when it is appropriate to start medications on an acute inpatient setting to help with maintenance of alcohol use disorder prior to discharge. Discussions about maintenance medications to prevent relapse should be strongly considered once a patient is considered medically stable after detoxification/withdrawal from alcohol. Discuss with the inpatient teams about risks/benefits of MAUD options.
2. What strategy do you recommend for aiding in continuity of care?
- An essential strategy as a pharmacist in aiding in continuity of care for patients taking MOUD is to identify and network with addiction treatment contacts within your facility and your community (i.e. know the Suboxone® and methadone clinics around your area, get to know your local addiction medicine providers, find out if there is a mental health consult service in your facility). Keeping strong professional connections with addiction medicine providers and contacts in all areas of care (outpatient, inpatient consult, treatment programs) can significantly help to facilitate smooth transitions of care for these patients.
- Another aspect to keep in mind as a pharmacist is to verify state prescription drug databases, as well as the medication doses and last fill dates for all medications. Within these databases, it is important to monitor for the prescribing and use of benzodiazepines and opioids with patients who are on MOUD due to the dangerous drug interactions and addiction potential of these medications.
3. What are some ways to communicate with inpatient providers to ensure appropriate patient care?
- Oftentimes inpatient providers are unfamiliar or uncomfortable with MAUD/MOUD medications and want to understand more about the evidence behind using these medications. Taking an academic detailing/educational approach can be an effective strategy Providers without expertise in addiction medicine may not be comfortable with prescribing these medications and should reach out to colleagues with more expertise for assistance. If recommendations are being made either verbally or written to inpatient providers regarding MAUD/MOUD, pharmacists should consider discussing some of the reference citations relating to the harm reduction and life-saving outcomes. Communication about outcomes and evidence-based treatment can be provided in many forms such as in-services, individual face-to-face, email, etc.
- Be sure to compile your local and facility resources and referrals that are available for psychiatry and addiction. For example, a great way to communicate with the inpatient providers and team is to recommend that the psychiatric/addiction consult service team (or another addiction medicine point person) discuss with the inpatient medical teams regarding MAUD/MOUD management and help provide education. A few resources that can be utilized include the Substance Abuse and Mental Health Services Administration (SAMHSA) website, the American Society of Addiction Medicine (ASAM) Principles of Addiction Medicine textbook, and the Veterans Affairs Management of Substance Use Disorder (SUD) 2021 Clinical Practice Guideline.
- Although not related to inpatient providers, group education for patients by pharmacists about MAUD/MOUD is a great strategy to communicate and allow them to ask questions regarding medications and concepts. Group education provides an excellent way for patients to share their stories with each other, identify and resolve misconceptions, and understand more about their care and the various options available to them.