Advanced and Innovative Techniques for Pain Management in Opioid Use Disorder: A Pharmacy-Psychiatry Collaboration Utilizing Full Agonist Opioids, Buprenorphine, and Ketamine

Abstract:

Background: Patients with opioid use disorder (OUD) present unique challenges for pain management due to high opioid tolerance, and require complex management of multi-modal analgesia. Frequently, patients with OUD self-discharge due to suboptimal pain control, limiting their access to equitable treatment (Ti 2015).

Case: A 54-year-old female with OUD was admitted under neurosurgery for management of spinal abscess, a complication of her prior spinal surgeries. The psychiatry team was consulted for management of OUD and in-hospital substance use, and collaborated with a substance use disorder clinical pharmacist to achieve analgesia and address opioid cravings. The patient was initially managed with a combination of immediate-release oxycodone overlapping with rapidly titrated methadone, but she reported ongoing severe pain. Oral ketamine was started and titrated with the patient reporting significant improvement in her pain. Over the course of her complicated admission, ketamine and full agonist opioids were adjusted to good effect without adverse events. Postoperatively, the patient maintained good pain control, completed a low-dose buprenorphine initiation in a cross-taper with methadone, and weaned off ketamine and full agonist opioids.

Discussion: This case illustrates several emerging techniques in the management of patients hospitalized OUD that our team regularly implements. Providing full agonist opioids, whether for the management of withdrawal or acute pain, is critical in helping patients remain comfortable enough to remain hospitalized (Thakrar 2023). Additionally, we have previously demonstrated that medically hospitalized patients can safely undergo rapid methadone titration, which is necessary for patients with high opioid tolerance for whom typical starting doses of methadone are inadequate (Todaro 2023). Leveraging ketamine and its ability to “reset” mu opioid receptors for individuals with high tolerance is an innovative strategy that our team implements with great success, despite minimal literature describing the use of ketamine for this purpose (Christian 2023). Lastly, we cross-tapered methadone with buccal buprenorphine utilizing a low-dose initiation strategy, the emerging standard in buprenorphine induction (Ahmed 2021).

Conclusion: Analgesia for patients with OUD, opioid withdrawal, and acute pre- and postoperative pain is difficult to achieve, often resulting in patient-directed discharges that contribute to medical disparities. Collaboration with pharmacists to develop and implement innovative strategies—such as full agonist opioids, rapidly titrated methadone, oral ketamine, and low-dose buprenorphine initiation—enabled this patient initially presenting with in-hospital substance use to complete all recommended treatment.

References:

Ahmed S, et al. Microinduction of Buprenorphine/Naloxone: A Review of the Literature. Am J Addict. 2021;30(4):305-315.

Christian NJ, et al. Precipitated Opioid Withdrawal Treated With Ketamine in a Hospitalized Patient: A Case Report. J Addict Med. 2023 Jul-Aug 01;17(4):488-490.

Thakrar AP, et al. Safety and preliminary outcomes of short-acting opioid agonist treatment (sOAT) for hospitalized patients with opioid use disorder. Addict Sci Clin Pract. 2023 Feb 24;18(1):13.

Ti L, Ti L. Leaving the hospital against medical advice among people who use illicit drugs: a systematic review. Am J Public Health. 2015;105(12):e53–e59.

Todaro DR, et al. Safety of Rapid Methadone Titration for Opioid Use Disorder in Hospitalized Patients: A Pilot Study. J Acad Consult Liaison Psychiatry. 2023 Nov-Dec 64(supplement): S87.

Presentation Eligibility: Not previously published or presented

Diversity, Equity, and Inclusion: This presentation discusses the management of patients with opioid use disorder and in-hospital substance use, a population that is frequently marginalized and stigmatized. Patients frequently self-administer opioids and self-discharge prior to completing treatment due to suboptimal management of their opioid use disorder, and therefore struggle to obtain adequate and equitable treatment. By learning how to adopt innovative and advanced pharmacologic strategies, as well as partner with a champion pharmacist, CL psychiatrists will learn to help these patients feel more comfortable in the hospital setting as an important step toward achieving better outcomes.