Jordan Ellis
Psychiatric hospitals are facilities that cater to patients with severe mental health issues who are no longer safe in the community. While psychiatric hospitals provide medical care, their capabilities are limited compared to general hospitals, and they primarily focus on psychiatric treatment. The use of opioid agonist therapy (OAT) medications like buprenorphine, methadone, and naltrexone is an evidence-based treatment for opioid use disorder (OUD). However, a recent study revealed that less than half of psychiatric hospitals in the US offer these medications, despite the high prevalence of OUD among psychiatric patients. This underutilization may be due to stigma and bias, but it represents a missed opportunity to initiate treatment and improve patient outcomes. While inpatient psychiatric hospitals can facilitate OUD treatment, they must carefully manage the risks of addiction relapse and overdose.
| Characteristics | Values |
|---|---|
| Opioid use disorder treatment in psychiatric hospitals | Fewer than half of psychiatric hospitals in the US have opioid use disorder treatments available for their patients |
| Opioid use disorder treatment medications | Buprenorphine, methadone, and naltrexone |
| Opioid agonist therapy | Methadone, buprenorphine, and diacetylmorphine |
| Buprenorphine treatment adverse effects | Constipation, headache, elevated transaminases in patients with chronic hepatitis C or alcohol use |
| Opioid treatment considerations | Duration of treatment, frequency of administration, risk of addiction relapse, lowest effective dose |
| Opioid treatment discharge considerations | Long-term addiction treatment options, harm reduction strategies, screening for infectious diseases and immunization status, limited opioid prescriptions for pain |
| Benefits of opioid treatment in hospitals | Increased likelihood of connecting with outpatient care, initiating treatment during a reachable moment, reducing stigma, lower opioid misuse |
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What You'll Learn
Opioid agonist therapy
OAT is particularly relevant for patients with both opioid use disorder and psychiatric disorders, as there is a significant overlap between these two conditions. Research has shown that more than a third of treatment-seeking patients with opioid use disorder also have a psychiatric disorder such as depression, anxiety, or bipolar disorder. This means that patients in psychiatric hospitals are even more likely to require opioid addiction treatment.
Despite the effectiveness of OAT, it is underutilized in psychiatric hospitals. A recent study found that fewer than half of psychiatric hospitals in the US have medications for opioid use disorder available for their patients. This discrepancy may be due to the stigma and bias surrounding addiction treatment, as well as the complex nature of treating patients with opioid use disorder in acute hospital settings.
OAT is recommended as a first-line therapy for opioid addiction. It is safer than detox alone, which can lead to a rapid loss of tolerance and an increased risk of fatal overdose if the patient relapses. OAT helps to stabilize patients and reduce the risk of overdose, with fewer and less severe side effects than other treatments. Methadone, a synthetic opioid agonist, is effective for treating opioid use disorder and withdrawal, but it also carries an increased risk of overdose if the dose is escalated too quickly. Buprenorphine-naloxone is another commonly used formulation that has a lower risk of overdose and drug interactions compared to full opioid agonists.
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Managing opioid withdrawal
Opioid withdrawal can be an uncomfortable and difficult process for the patient, often likened to a bad case of the flu. While it is typically not life-threatening, careful management is required, especially in certain cases such as with pregnant women, where withdrawal can lead to miscarriage or premature delivery.
Inpatient Management
Inpatient withdrawal is recommended in certain circumstances, such as when an individual has social factors that may hinder their ability to cease drug use, or if they have co-occurring physical or psychological disorders. Inpatient care for opioid withdrawal can be medically and psychosocially complex.
Medication
Buprenorphine is a commonly used medication for managing opioid withdrawal. It is a partial opiate agonist, and alleviates withdrawal symptoms while reducing cravings. It should be administered with caution, and the dosage must be reviewed and adjusted daily based on the patient's response and the presence of side effects. The dose required is also dependent on the amount and type of opioid previously used by the patient.
Methadone is another medication used to manage opioid withdrawal. It is useful for detoxification from longer-acting opioids and reduces cravings. Similar to buprenorphine, the dosage must be carefully monitored and adjusted, and it should be used with caution in certain cases, for example, if the patient has a history of cardiac issues.
Additional Support
During opioid withdrawal, patients should be monitored regularly for symptoms and complications, and the Short Opioid Withdrawal Scale (SOWS) can be a useful tool for this. Patients should also be encouraged to stay hydrated by drinking at least 2-3 litres of water per day, and to take vitamin B and C supplements.
Therapy
Therapy with opioid agonists, including methadone, buprenorphine, and diacetylmorphine, can be used for the long-term treatment of opioid use disorder and the acute management of withdrawal symptoms.
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Safe discharge practices
Medication Management
Before discharge, providers should have detailed discussions with patients about their long-term addiction treatment options and harm reduction strategies. This includes exploring medication options such as opioid agonist therapy with drugs like methadone, buprenorphine, or diacetylmorphine, which can be used for long-term treatment and acute withdrawal management. It is crucial to taper off these medications gradually over several days if patients are not continuing opioid agonist therapy after discharge, as abrupt discontinuation can lead to severe withdrawal symptoms.
Patient Education and Informed Consent
Physicians should inform patients about the risks and benefits of opioid use, particularly the risk of future chronic opioid use associated with opioid prescriptions at discharge. Patients should provide informed consent and be actively involved in decisions regarding their pain management and addiction treatment plans.
Discharge Planning
Safe discharge planning involves coordinating ongoing care and support for patients. This includes facilitating connections to outpatient care and addiction treatment services to ensure continuity of treatment and reduce the risk of relapse. Providers should also screen for infectious diseases, assess immunization status, and address any comorbid medical or psychological conditions that may impact the patient's recovery.
Follow-up Appointments and Monitoring
Increasing the frequency of follow-up appointments after discharge can help assess the ongoing need for pain medication and monitor for potential substance use issues. Close monitoring can also help identify patients at high risk for opioid abuse or chronic use, allowing for early intervention and prevention of adverse outcomes.
Adjunct Treatments
In addition to medication management, offering adjunct treatments such as family therapy and psychosocial interventions can improve patient outcomes. These approaches can enhance recovery, reduce stigma, and provide patients with additional tools to manage their mental health and substance use disorders.
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Overlap between opioid use disorder and psychiatric disorders
Opioid use disorder (OUD) is a chronic medical disease that can have serious consequences, including disability, relapse, and death. It is characterised by a pattern of opioid use leading to problems or distress, with symptoms such as persistent cravings, increased tolerance, and unsuccessful efforts to control opioid use. OUD often co-occurs with psychiatric disorders, and this overlap is significant. Research has shown that more than a third of treatment-seeking patients with OUD also have a psychiatric disorder. These co-occurring disorders can include depression, anxiety, bipolar disorder, and other mental health conditions.
The relationship between OUD and psychiatric disorders is complex and interconnected. People with mental disorders are at an increased risk of developing substance use problems, including opioid addiction. Conversely, those with OUD may also experience psychiatric disorders, and this dual diagnosis can complicate treatment and care. The presence of both conditions can exacerbate the symptoms of each, creating a cycle that is challenging to break.
Several factors contribute to the development of OUD, including genetic predispositions, such as mutations in the opioid receptor gene, and environmental influences, such as exposure to trauma or access to prescription opioids. The use of opioids can produce feelings of euphoria, leading individuals to continue their use despite negative consequences. Additionally, the availability of prescription opioids, heroin, and fentanyl has contributed to the growing opioid epidemic, with an estimated 8.6 million Americans misusing prescription opioids in 2023.
Treating OUD in psychiatric hospitals is complex and requires careful consideration. While medications for OUD are available in outpatient clinics, their availability in psychiatric hospitals is limited. This discrepancy may result from the stigma and bias associated with addiction treatment, preventing providers from recognising it as a treatable condition. However, making these medications more accessible in psychiatric hospitals could benefit patients who might not otherwise seek out treatment for OUD. Initiating treatment during hospitalisation can increase the likelihood of patients connecting with outpatient care and improving their overall illness trajectory.
To address this issue, organisations like the National Institute on Mental Health (NIMH) are supporting research to expand therapeutic options for OUD and co-occurring mental disorders. The NIMH's Helping to End Addiction Long-term® Initiative (NIH HEAL Initiative®) aims to optimise the delivery of services for individuals with OUD, mental disorders, and suicide risk. Additionally, clinical trials are exploring new ways to prevent, detect, and treat OUD and mental health conditions, with a focus on improving treatment standards and patient outcomes.
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Stigma and bias
The stigma surrounding substance use disorder is deeply ingrained and can prevent individuals from seeking help. It can manifest in three forms: social stigma, self-stigma, and structural stigma. Social stigma involves negative stereotypes and labels, such as "addict" or "alcoholic", that distance and exclude individuals with SUDs. Self-stigma occurs when individuals internalize these negative beliefs, leading to feelings of shame and a fear of seeking treatment. Structural stigma refers to discriminatory laws and policies that negatively impact individuals with SUDs. These forms of stigma overlap and reinforce each other, creating significant barriers to help-seeking and open conversations about substance use disorders.
Language plays a crucial role in perpetuating stigma and bias. Commonly used terms like "junkie" and "addict" contribute to negative biases and dehumanize individuals with SUDs. Research shows that language can influence clinicians' attitudes, with those described as "substance abusers" being viewed more negatively than those described as having a "substance use disorder." Treating drug use as a criminal act further fuels stereotypes of individuals with SUDs as dangerous and reinforces stigma.
Racial disparities and discrimination add another layer of stigma and bias. People of color, particularly Black individuals, experience delays and reduced access to treatment for substance use disorders. They are also disproportionately affected by punitive policies and are more likely to be arrested for illegal drug use. Cultural backgrounds of healthcare professionals can also influence the attitudes and care they provide, with certain cultural beliefs contributing to harsh judgments about illicit drug use.
Addressing stigma and bias is crucial to improving access to care and reducing the negative consequences associated with substance use disorders. This includes challenging negative stereotypes, promoting the use of non-stigmatizing language, and increasing awareness and understanding of substance use disorders among healthcare professionals and the general public. By tackling stigma and bias, we can create a more inclusive and supportive environment for individuals seeking treatment and improve their overall health and well-being outcomes.
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Frequently asked questions
Psychiatric hospitals are not medical hospitals. They typically cannot provide IV fluids, IV medication, or oxygen therapy due to ligature risk concerns. However, psychiatric hospitals do provide medical care. Most have internists, family medicine doctors, and paediatricians on staff who offer medical care and consultations. Inpatient psychiatric stays are not limited to 72 hours. The length of stay is determined by the treatment team and depends on the patient's progress and treatment completion.
Opiates may be prescribed in limited amounts for pain management, but only when indicated. Therapy with opioid agonists like methadone, buprenorphine, and diacetylmorphine can be used for long-term treatment and acute withdrawal management. Buprenorphine treatment is relatively low-cost and can help stabilize patients, reducing hospital readmissions.
There is a significant overlap between patients with opioid use disorder and psychiatric disorders. Initiating treatment for opioid use disorder in a hospital setting can help patients connect with outpatient care. However, stigma and bias may prevent providers from recognizing addiction as a treatable condition.
Patients with untreated opioid use disorder may require multiple hospital readmissions.
There is a risk of addiction relapse, and overdose is possible if the dose is escalated too quickly.
Initiating opioid use disorder treatment in a hospital setting can increase the likelihood of patients connecting with outpatient care.
