As opioid-related hospitalizations and overdose deaths continue to surge in the U.S., the role of hospitalists in initiating treatment for opioid use disorder (OUD) has never been more urgent. Many hospitals still lack dedicated addiction medicine consultation services, yet the clinical consequences of substance use disorders (SUDs), including withdrawal, overdose, pain, delirium, self-directed discharge, and readmission, are encountered daily on hospitalist services. The speakers delivered a practical, case-based roadmap for hospitalists to provide evidence-based, compassionate addiction care without waiting for specialty backup.
The central message was direct: Treating addiction is within the hospitalist’s scope of practice when hospitalists are empowered with the right resources. Speakers emphasized that patients hospitalized with SUDs are not “social problems” separate from the medical admission. Their message was that addiction medicine in a hospital setting is part of hospital medicine: clinicians can diagnose SUDs, treat withdrawal and pain, initiate medications, reduce stigma, and create safer transitions of care.
The session opened with the case of Nick, a patient admitted for a hand injury who screened positive for unhealthy alcohol use. Dr. Christian emphasized that hospitalists could diagnose SUD, including alcohol use disorder (AUD), using DSM-5 criteria. This framework assesses impaired control, social impairment, risky use, and pharmacological features such as tolerance and withdrawal. For alcohol use, the CAGE questionnaire can help identify patients at higher risk, but diagnosis remains clinical and should be based on history, functional impact, consequences, and pattern of use.
OUD was then explored through the case of Phinny, a young woman with daily fentanyl use admitted with severe pain and infection of the arm. Her case reflected common inpatient challenges: prolonged ED boarding, severe acute pain, high opioid tolerance, anxiety about withdrawal, prior negative buprenorphine experience, and no available addiction consultation service. Dr. Christian reinforced that initiation of medication for opioid use disorder (MOUD) in the hospital is standard of care and should be within the hospitalist’s scope of practice.
Buprenorphine and methadone were presented as first-line medications for hospitalized adults with OUD. Use adjunctive medications such as clonidine, loperamide, nonsteroidal anti-inflammatory drugs, acetaminophen, ondansetron, and hydroxyzine when appropriate. Methadone may be useful for patients with significant withdrawal, severe pain, high fentanyl tolerance, or a preference for methadone treatment. Buprenorphine may be initiated traditionally when a patient has objective opioid withdrawal, or by low-dose initiation when withdrawal timing is uncertain, or the patient cannot tolerate opioid abstinence.
Stigma was presented as a modifiable clinical risk factor. The presenters showed how stigma appears in the chart, at the bedside, and in hospital policy through terms such as “drug-seeking,” dismissive communication, undertreatment of pain or withdrawal, punitive searches, and withholding of needed care. Recovery-oriented care requires person-first language, politeness, open communication, and shared decision making. These behaviors are not merely compassionate; they improve trust and may reduce the likelihood that patients leave before completing treatment for infections, wounds, surgery, or withdrawal.
In-hospital substance use was discussed using Phinny’s case after she was found using a substance in the bathroom. The recommended response was clinical assessment, not automatic discharge or punishment. Hospitalists should ask why the patient used: Was withdrawal undertreated? Was pain uncontrolled? Did the patient feel ignored, judged, or unsafe? The appropriate response includes assessing sedation and overdose risk, providing adequate pain control, offering evidence-based addiction treatment, clarifying hospital policy, and avoiding unnecessary security escalation. Patient-centered policies can reduce harm while maintaining safety for patients and staff.
Dr. South described MOUD initiation in the fentanyl era, which requires flexibility. Fentanyl exposure can make withdrawal timing unpredictable and may increase the fear of precipitated withdrawal. For hospitalized patients with ongoing pain or recent fentanyl use, rapid methadone or low-dose buprenorphine initiation protocols with concurrent use of short-acting full agonists like oxycodone or hydromorphone for acute pain improved outcomes.
Continuing home buprenorphine during hospitalization improves overall treatment compliance, and split dosing may improve analgesia. Clinicians should use multimodal non-opioid therapies and add short-acting opioids at appropriately higher doses when clinically indicated. Inadequate pain control is not a neutral decision; it worsens mistrust, increases suffering, and contributes to self-directed discharge. Asking patients what has worked for their pain in the past is a practical and respectful way to begin the conversation.
Drug supply contaminants, including xylazine and medetomidine, were also reviewed. The presenters emphasized that the current illicit drug supply is unpredictable and may contain agents not detected by routine urine drug screens. Hospitalists should recognize unusual sedation, wounds, and overdose patterns; however, the broader management remains supportive and should include treatment of withdrawal with MOUD, symptom-triggered medication such as clonidine or benzodiazepines when appropriate, and naloxone for suspected opioid overdose.
AUD treatment was framed as another missed opportunity in hospital medicine. Initiating medications for AUD (MAUD) in the hospital in addition to benzodiazepines for acute withdrawals decreases heavy drinking days, 30-day readmission rates, and emergency department visits. Oral naltrexone is more feasible compared to injectable naltrexone. Oral form can be started as 25 mg daily for three days, then 50 mg daily, and can be titrated to a maximum dose of 100 mg daily. Avoid naltrexone in severe liver disease (Child-Pugh Class C). Acamprosate is preferred in severe liver disease (Child-Pugh class C); start 666 mg three times daily after five to 10 days of abstinence (reduce to twice daily for patients under 60 kg). Avoid if creatinine clearance is under 30 mL/min. Gabapentin and other agents may be individualized based on symptoms, comorbidities, and outpatient feasibility. The key lesson was to treat AUD longitudinally, not only during withdrawal.
For stimulant use disorder, the presenters used Rebecca’s case, a patient admitted with psychosis after IV methamphetamine use, to emphasize that no U.S. Food and Drug Administration-approved medications currently exist. Hospitalists should manage medical and psychiatric complications, provide a calm environment, address co-occurring substance use or mental health disorders, offer harm reduction, prescribe naloxone when appropriate, and link patients to community resources. Contingency management remains the best-supported behavioral intervention.
The session also addressed dangerous benzodiazepine use. Hospitalists should avoid abrupt discontinuation, clarify the indication, assess overdose risk and co-occurring disorders, coordinate with outpatient prescribers, and use slow patient-centered tapers when appropriate.
This session was highly relevant to everyday hospital medicine practice. It reframed addiction care as acute medical care, not optional counseling. The presenters made clear that hospitalists can diagnose substance use disorders, treat withdrawal, start MOUD and MAUD, manage pain, reduce stigma, respond constructively to in-hospital substance use, and create safer discharges. The most important “hot take” was also the most practical: when hospitalists treat addiction with the same urgency and professionalism as sepsis, heart failure, or diabetes, hospitalization becomes a lifesaving window for recovery.
Dr. Talari
Dr. Talari is a hospitalist and vice chair of the department of medicine at AdventHealth in DeLand, Fla., and assistant professor at Florida State University College of Medicine in Daytona Beach, Fla.