How to manage a patient with severe opioid use disorder, admitted for endocarditis, experiencing opioid withdrawal, and requesting to leave against medical advice (AMA) to use heroin?

Managing Opioid Withdrawal and AMA Risk in a Patient with Endocarditis and Severe OUD

Immediately initiate buprenorphine or methadone to treat opioid withdrawal and stabilize the patient, as this is the single most effective intervention to prevent AMA discharge, ensure completion of IV antibiotic therapy for endocarditis, and reduce mortality risk. 1, 2

Immediate Pharmacologic Management of Withdrawal

Start medication for opioid use disorder (MOUD) urgently—do not wait for the patient to stabilize or complete endocarditis treatment first. The evidence is clear that initiating MOUD during hospitalization for endocarditis results in 5.7 additional days of gold-standard IV antibiotic treatment compared to no MOUD 1. This directly addresses the life-threatening infection while simultaneously treating the underlying addiction.

Buprenorphine Initiation Protocol

• Begin buprenorphine/naloxone (preferred formulation to prevent diversion) once the patient is in mild-to-moderate withdrawal to avoid precipitated withdrawal 3, 4
• Start with standard induction dosing (typically 4-8 mg sublingual on day 1, titrated to effect) 3
• Buprenorphine can simultaneously manage both opioid withdrawal AND acute pain from endocarditis, making it ideal for this clinical scenario 5
• Monitor for respiratory depression if combining with benzodiazepines or other CNS depressants, though this risk is lower with buprenorphine than full agonists 4

Alternative: Methadone

• If buprenorphine is contraindicated or the patient refuses it, methadone is equally effective for preventing AMA discharge in endocarditis patients 1
• Methadone can be initiated in the hospital setting for acute withdrawal management and continued as maintenance therapy 3

Critical Communication Strategy

Use motivational interviewing techniques rather than confrontational approaches, as confrontation increases AMA risk 3:

• Elicit the patient's own concerns: "What worries you most about your heart infection?" rather than "Don't you see this could kill you?" 3
• Explore ambivalence: "What do you like about using heroin? What makes you think about stopping?" 3
• Provide tailored information: "Even if you leave now, the infection in your heart can cause a stroke or kill you within days. The antibiotics we're giving you are the only treatment that works." 3
• Affirm any positive statements: If the patient expresses any concern about their health, reflect it back: "You're worried about what might happen—that tells me you care about your future." 3

Address Underlying Drivers of AMA Intent

The triad of hospitalization, self-efficacy, and easily accessible patient-centered treatment motivates change in opioid use 2. Leverage this moment:

Pain Control

• Ensure adequate pain management using MOUD plus non-opioid adjuncts (NSAIDs, acetaminophen, gabapentin for neuropathic components) 2, 5
• Inadequately controlled pain is a major driver of AMA discharge 2

Mental Health Stabilization

• Screen for and treat co-occurring depression, anxiety, or other psychiatric conditions, as these contribute to treatment discontinuation 2
• Consider short-term benzodiazepines for severe anxiety if needed, but use lowest effective doses given respiratory depression risk with opioids 6, 4

Social Support and Discharge Planning

• Begin discharge planning immediately—do NOT wait until antibiotics are complete 2
• Stable housing and social support are prerequisites for MOUD continuation, so engage social work urgently to address these barriers 2
• Arrange outpatient parenteral antimicrobial therapy (OPAT) if feasible, as this may be appropriate even for people who inject drugs when paired with MOUD and addiction treatment 5
• Connect to outpatient addiction treatment BEFORE discharge, as this pairing dramatically improves outcomes 5

If Patient Still Insists on Leaving AMA

Do not abandon the patient or withhold information and medications 7:

• Provide written discharge instructions about endocarditis complications (stroke, heart failure, death), signs of worsening infection, and when to return 7
• Prescribe or provide medications: Give buprenorphine prescription or supply, antibiotics if oral options exist, and any other necessary medications 7
• Provide naloxone and overdose prevention education, as patients leaving AMA are at extremely high risk of overdose death given decreased tolerance during hospitalization 3
• Give explicit follow-up information with specific appointments for addiction treatment, infectious disease, and cardiology 7
• Emphasize the patient can return at any time for continued care without judgment 7

Critical Pitfalls to Avoid

• Never discharge a patient from your practice or refuse future care because they left AMA—this violates the principle of nonabandonment 8
• Do not delay MOUD initiation waiting for "the right time" or completion of antibiotic therapy—early initiation is what prevents AMA discharge 1, 2
• Avoid confrontational language like "you're going to die if you leave"—this increases defensiveness and AMA risk 3
• Do not assume the patient is "drug-seeking" when requesting pain medication—inadequate pain control drives AMA discharge 8, 2
• Never use unexpected behaviors as justification to withhold treatment—this represents a failure to treat the underlying disease 8

Evidence on Outcomes

Patients with O-IE who leave AMA have a 50% 30-day readmission rate compared to 21% for other discharge types 9. DAMA is strongly associated with readmission (OR 3.72) and patients experience more total hospitalizations during the year 9. However, initiating MOUD reduces this risk by ensuring completion of antibiotic therapy 1. The mortality risk from untreated endocarditis far exceeds any theoretical risk from initiating MOUD in the hospital setting 3, 5.