Managing inpatients with substance abuse disorders

The number of patients with substance abuse disorders who are admitted to hospitals as inpatients has been steadily increasing.¹ Hospitalists attending SHM Converge 2025, the annual meeting of the Society of Hospital Medicine (SHM) in Las Vegas this spring, were given practical advice on how to treat these patients. 

An estimated 6.1 million individuals in the United States have an opioid disorder, according to the 2022 National Survey on Drug Use and Health.² The US National Institute on Alcohol Abuse and Alcoholism reports that 28.9 million people aged 12 and older had alcohol use disorder in 2023.³ 

Patients admitted to a hospital emergency department with a drug or alcohol overdose are initially treated by emergency clinicians and emergency pharmacists. When any patient with substance abuse disorder becomes an inpatient, hospitalists have the responsibility of initiating medication protocols to reduce dependency. 

Opioid use disorder

Anna-Maria South, MD

Photo courtesy of Dr South

Anna-Maria South, MD, of the Division of Hospital Medicine at the University of Kentucky College of Medicine in Lexington, discussed the protocol used at her hospital and the importance of encouraging a Medications for Opioid Use Disorder (MOUD) drug regimen to prevent opioid withdrawal. First, testing is needed.⁴ 

The Clinical Opiate Withdrawal Scale (COWS) is an eleven-item tool administered by a clinician to rate common signs and symptoms of opioid withdrawal and monitor the symptoms over time. Resultant scores can help clinicians determine the stage or severity of opioid withdrawal and assess the level of physical dependence. A COWS score grade of 8 or greater is indicative of withdrawal symptoms.⁵ 

Buprenorphine is a synthetic opioid, which as a partial agonist, can block withdrawal symptoms. It has low misuse potential and low toxicity. For patients experiencing opioid withdrawal with a COWS score of 8 or greater, Dr South recommends 4 mg of buprenorphine, with an additional 4 mg administered every 2-4 hours as needed for continued withdrawal symptoms, for a maximum of 16 mg on Day 1. This protocol is repeated on Day 2, with a maximum dose of 16 mg per day, and on Day 3 onward with a maximum dose of 24 mg per day. Opioid use disorder is usually successfully treated with a dose of 16 to 32 mg daily. 

A low dose (micro-dosing) regimen of buprenorphine may be appropriate for patients who are currently prescribed a full opioid agonist and elect not to wean or enter withdrawal, and for patients who use fentanyl regularly. The full agonist opioid is continued as prescribed. Buprenorphine is started at a very low dose, with the dose slowly increased daily for a week. This will very slowly displace the full opioid agonist. This regimen avoids the precipitated withdrawal caused by larger doses of buprenorphine. 

Precipitated withdrawal

Precipitated withdrawal, recognized by a sudden increase in the COWS score within 20-60 minutes after receiving buprenorphine, is a debilitating experience, marked by rapid onset of symptoms such as body aches, nausea, vomiting, diarrhea, and abdominal cramps. Patients who use opioids may be frightened, and if experiencing it, they may check out of the hospital before recommended discharge and may decline further buprenorphine treatment. It is difficult to convince a patient who has gotten sick from buprenorphine once to take more of it. 

‘Patients who have been using illicit opioids and want to start buprenorphine for MOUD are good candidates for the low dose buprenorphine protocol,’ commented Dr South. ‘To make sure the patient who does not have a prescribed opioid regimen but is taking a full agonist daily, I start by giving oxycodone (20-25 mg every four hours) simultaneously with low doses of buprenorphine. The objective is to prescribe a daily dose that will be enough to compensate for the opioid deficit by administering the full agonist to keep receptors satisfied, then slowly displacing them. If precipitated withdrawal starts to occur, treat the symptoms aggressively with 4 mg or 8 mg dose of buprenorphine every hour.’ 

If a patient needing MOUD is admitted to a hospital for reasons which may not require a weeklong hospitalization, a three-day protocol may be more appropriate. The full agonist is administered for the first two days in conjunction with buprenorphine, then discontinued on a third day with a frequent 24-hour dosing schedule of buprenorphine. 

‘Patients with an opioid use disorder have as six times greater death risk than the general population. Those on a MOUD just have a two times greater risk. Hospitalists play an important role in reducing death risk. They can test for transmittable diseases, prescribe naloxone, and provide information about resources. These include sources to obtain clean needles/syringes, MOUD providers and free-of-charge primary care clinics,’ she said. 

Alcohol use disorder

Patients admitted as inpatients who have with a potential alcohol use disorder may be identified using the Alcohol Use Disorders Identification Test – Consumption (AUDIT-C).⁶ The Prediction of Alcohol Withdrawal Severity Scale (PAWSS) helps clinicians identify patients who may be at high risk for developing complicated alcohol withdrawal syndrome. This occurs when a patient has a score of 4 or higher. 

Keri Holmes-Maybank, MD

Photo courtesy of Dr Holmes-Maybank 

Keri Holmes-Maybank, MD, of the Medical University of South Carolina (MUSC) in Charleston, recommends that all hospitals establish treatment protocols. Over the past decade, phenobarbital has been used in hospital emergency departments because it has a long half-life of 53 to 140 hours. But no standardized or universal protocols have been established for inpatients. 

The American Society of Addiction Medicine (ASAM) recommends the administration of phenobarbital only for individuals experiencing severe alcohol withdrawal, who are at great risk for this, or who have a contraindication for benzodiazepine use. ASAM advises that it should only be used by clinicians experienced with its use, given its narrow therapeutic window and side effects.⁷ 

Phenobarbital is associated with severe adverse reactions of the nervous system, cardiovascular events, nausea, vomiting, constipation, apnea, and hypotension. Hospitals should not administer it if staff is not available to closely monitor the patient. ‘The drug is a reasonable alternative to benzodiazepine, especially when your patient has challenging or refractory alcohol withdrawal or benzodiazepine-resistant alcohol withdrawal,’ said Dr Holmes-Maybank. ‘There is not enough data to say what the best protocol is. At MUSC, we administer 260 mg followed by two doses of 130 mg.’ 

She advised that only about one percent of individuals in the US with alcohol use disorder are receiving medication for alcohol use disorder (MAUD). Naltrexone is the drug of choice for treatment, or acamprosate if a patient has a contraindication to naltrexone. The challenge for hospitalists is to get patients through their alcoholic withdrawals before starting a MAUD regimen. 

‘Hospitalization is a reachable moment for initiating MOUD and MAUD, and can help the patient to get connected with outpatient care. Harm reduction, whether for opioid drugs or alcohol, does not require total abstinence. Every quit attempt counts. It is a step toward recovery. Don’t give up’, she concluded. 

References: 

1. Suen LW, Makam AN, Snyder HR, et al. National Pevalence of Alcohol and Other Substance Use Disorders Among Emergency Department Visits and Hospitalizations: NHAMCS 2014-2018. J Gen Intern Med. 2021. 13;37(10):2420–2428. doi:10.1007/s11606-021-07069-w. 
2. U.S. Food and Drug Administration. Information about Medications for Opioid Use Disorder (MOULD). Internet accessed on June 10, 2025. https://www.fda.gov/drugs/information-drug-class/information-about-medications-opioid-use-disorder-moud and https://www.samhsa.gov/data/sites/default/files/reports/rpt42731/2022-nsduh-nnr.pdf 
3. National Institute on Alcohol Abuse and Alcoholism. Alcohol’s Effects on Health: Alcohol Use Disorder (AUD) in the United States: Age Groups and Demographic Characteristics. September 2024. Internet accessed on June 10, 2025 https://www.niaaa.nih.gov/alcohols-effects-health/alcohol-topics/alcohol-facts-and-statistics/alcohol-use-disorder-aud-united-states-age-groups-and-demographic-characteristics. 
4. Holmes-Maybank K, South AM. ‘No Addiction Medicine Service? No Problem! Things You Need to Know to Care for Patients with Substance Abuse Disorders”. SHM Converge 2025, 23-25 April 2025.Las Vegas, NV. 
5. National Institute on Drug Abuse (NIDA). Clinical Opiate Withdrawal Scale. September 2, 2015. Internet accessed on June 6, 2025https://nida.nih.gov/sites/default/files/ClinicalOpiateWithdrawalScale.pdf 
6. Simon CB, McCabe CJ, Matson TE, et al. High test–retest reliability of the Alcohol Use Disorders Identification Test–Consumption (AUDIT-C) questionnaire completed by primary care patients in routine care. Alcohol Clin Exp Res (Hoboken). 2024;48(2):302–8. 
7. American Society of Addiction Medicine.The ASAM Clinical Practice Guideline on Alcohol Withdrawal Management: Executive Summary. 2020. p.18. 

Profiles: 

Keri Holmes-Maybank, MD, is a hospitalist and an Associate Professor in the College of Medicine at the Medical University of South Carolina. She is core faculty for addiction medicine in the internal medicine residency program. Dr Homes-Maybank is involved with multiple national organizations serving as the vice chair for the Society of Hospital Medicine Substance Use Disorders Special Interest Group and Co-Director of the Academic Hospitalist Academy. 

Anna Maria South, MD, is an addiction medicine physician and an Assistant Professor of Medicine at the University of Kentucky College of Medicine in Lexington. She is the chair for the Society of Hospital Medicine Substance Use Disorders Special Interest Group. Dr South is also the assistant director of the Health Equity and Advocacy Thread for the College of Medicine, an initiative to ensure that the medical school curriculum helps students to learn how to address health inequities and to provide patient-centred care for patients from diverse backgrounds. 

18.09.2025

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