Treatment of Refractory Opioid Use Disorder

Excerpt

In our article, “Comparison of Treatment Options for Refractory Opioid Use Disorder in the United States and Canada: a Narrative Review,” we presented a patient who had experienced recurrent complications from opioid use disorder to explore how evidence-based treatments and harm reduction approaches available in Vancouver, Canada, but restricted in the United States (U.S.) could have altered his circuitous, costly, and morbid clinical course.¹ The accompanying figure presented a linear timeline, illustrating admissions to acute and post-acute care, dispositions, and efforts by the hospital Addiction Consult Service to engage the patient in treatment with methadone, buprenorphine, and extended-release naltrexone (the only three Food and Drug Administration approved medications for opioid use disorder (OUD) in the U.S.). In their letter, Li, Mitton, and Bearnot recommend that journey mapping be used to better visualize and analyze this patient’s care from the patient’s own perspective. Approaches like journey mapping, which center around the patient’s experience of care, can certainly yield important insights as Bearnot and Mitton have previously demonstrated with OUD-associated endocarditis.² As they acknowledge in the last sentence of their letter and in their manuscript, much of the power of journey mapping lies in the visual comparison of patient experiences from their perspectives. Our linear timeline provides an absolute representation of a single patient’s interaction with the health system from the perspective of us as providers and the health care system. Rather than formulating this case as a patient who is not ready for treatment or who has such severe addiction that he cannot be treated, this patient’s story highlights that we, as providers, and the health system could and should do more. Thus, we presented evidence for the use of pharmacy-based methadone, slow-release oral morphine, injectable opioid agonist therapies, and hospital-based supervised injection services—approaches which would have been available to this patient had he been hospitalized in Vancouver rather than Boston. …