What role can hospital medicine physicians play in treating patients with opioid use disorder?

Opioid use disorder is a common comorbidity in hospitalized patients, but may pose a challenge to hospital-based providers who often care for patients with this chronic conditions only for a few days. Recent evidence suggests, however, that hospitalists can play an important role in helping these patients with their addiction problems.  A study that implemented screening, brief intervention, and referral to treatment (SBIRT) in hospital settings concluded that illicit drug use decreased by 67.7% at 6 months in patients who underwent such intervention (1). Opioid substitution therapy may also be an option in hospitalized patients. A randomized-controlled trial of patients who underwent hospital-initiated buprenorphine/naloxone therapy followed by referral to primary care providers found a 41% increase in patient engagement with addiction treatment at 30 days in the intervention group compared to the group that received only referral for treatment (2).

1. Madras B, Compton W, Avula D, et al. Screening, brief interventions, referral to treatment (SBIRT) for illicit drug and alcohol use at multiple healthcare sites: comparison at intake and 6 months later. Drug Alcohol Depend. 2009;99:280-295.

2. D’Onofrio G, O’Connor P, Pantalon M, et al. Emergency department-initiated buprenorphine/naloxone treatment for opioid dependence: a randomized clinical trial. JAMA 2015;313:1636-44.

 

Contributed by Ethan Balgley, Harvard Medical Student

What role can hospital medicine physicians play in treating patients with opioid use disorder?

Does marijuana use lead to any adverse cardiovascular effects?

Although marijuana is often not considered to have serious cardiovascular effects, in animal studies THC, the active ingredient in cannabis, has been found to affect cardiovascular activity through a number of mechanisms, including inhibition of adrenal catecholamine secretion and modulation of cardiac vagal tone through inhibition of norepinephrine release from sympathetic neurons (1). There have also been reports of temporal association between marijuana use and acute coronary syndrome, cardiac arrhythmias, cerebrovascular events, including TIA’s, strokes, and cerebral vasospasm, as well as peripheral vascular events, including arteritis, Raynaud’s phenomenon, and digital necrosis (2). In a recent comprehensive case series, about 2.0 % of all cannabis-associated adverse events were reported cardiovascular in nature, with 25% resulting in death (2). However, it is often difficult to determine the relative contribution of marijuana and other concurrent conditions or substances (e.g. alcohol and tobacco) when cardiovascular complications occur. More research in this area is needed.

1. Szabo B, Nordheim U, Niederhoffer N. Effects of cannabinoids on sympathetic and parasympathetic neuroeffector transmission in the rabbit heart. J Pharmacol ExpTher 2001; 297:819-826.

2. Jouanjus E, Lapeyre-Mestre M, Micallef J, et al. Cannabis use: signal of increasing risk of serious cardiovascular disorders. J Am Heart Assoc 2014; 3:e000638

Contributed by Pierre Ankomah, MD, Boston, MA

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Does marijuana use lead to any adverse cardiovascular effects?