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Teachable Moment
January 14, 2019

Initiating Opioid Agonist Treatment for Opioid Use Disorder in the Inpatient Setting: A Teachable Moment

Author Affiliations
  • 1Department of Psychiatry and Behavioral Sciences, Stanford University School of Medicine, Stanford, California
JAMA Intern Med. 2019;179(3):427-428. doi:10.1001/jamainternmed.2018.6749

A 21-year-old woman with a history of multiple hospital admissions for sepsis secondary to injection heroin use presented to the hospital with a right thigh abscess and dyspnea. Her diagnostic workup revealed pulmonic valve endocarditis, with both abscess and blood cultures growing methicillin-sensitive Staphylococcus aureus. The patient developed sepsis with respiratory failure and was intubated. Despite 11 days of treatment with antibiotics, her condition worsened and necessitated pulmonic valve replacement. She improved after surgery and received intravenous antibiotics for 6 weeks. She also received 220 morphine milligram equivalents for postoperative pain. Based on concerns that she would be at high risk to use her peripherally inserted central catheter to inject heroin as an outpatient, the decision was made to keep her hospitalized while completing the course of antibiotics.

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    1 Comment for this article
    "12 step facilitation" as part of a teachable moment
    Alan Wartenberg, MD, FACP, DFASAM | Affiliated Faculty, Brown University Center for Alcohol and Addiction Studies
    I am frequently distressed by highly competent and well-meaning physicians and other health care professionals who appear to believe that referral to 12-step programs in the only appropriate and viable way to get patients involved in mutual help. It is particularly ironic that a patient who was just started on medication-assisted therapy would be considered for such a referral. 12-step programs, and particularly Narcotics Anonymous, have long had a policy (Bulletin Number 29) that views those who are receiving opioid agonist therapy as "still using," and recommends that such patients, while welcome at meetings and not be allowed to speak or otherwise participate, other than listening. At many meetings, other members will strongly urge the individual to discontinue their medication, and such patients may be highly stigmatized if they continue to attend. Our hospital based program presented such patients on whom we were consulted with a number of strategies to deal with what they might experience at such meetings. We also informed them of other mutual help programs, including SMART Recovery, LifeRing Secular Recovery, Secular Organizations for Sobriety, Refuge Recovery and others. 12-step treatment can have serious unintended "adverse reactions" in patients who are placed on methadone and/or buprenorphine.