Management of Opioid Use Disorder in the Emergency Department

Introduction

Over the past year, a group of physicians and pharmacists with expertise in emergency medicine, toxicology, and addiction medicine developed a white paper for the American Academy of Emergency Medicine (AAEM) on Management of Opioid Use Disorder in the Emergency Department. It is our attempt to share current best practices and provide comprehensive evidence-based recommendations for providers in acute care settings managing patients being harmed-or at risk to be harmed-by opioids.

The guideline is set up as 48 discrete, commonly-encountered questions with extensively-referenced, high-yield answers answer based on available evidence and expert consensus within our group.

The Writing Group

Reuben J. Strayer, MD; Department of EM, Maimonides Medical Center Brooklyn, NY

Kathryn Hawk, MD, MHS; Department of EM, Yale School of Medicine, New Haven, CT

Bryan D. Hayes, PharmD; Department of EM, Department of Pharmacy, Harvard Medical School, Massachusetts General Hospital, Boston, MA

Andrew A. Herring, MD; Department of EM, University of California at San Francisco, Highland Hospital-Alameda Health System, Oakland, CA

Eric Ketcham, MD, MBA; Department of EM, Department of Behavioral Health, Addiction Medicine, Presbyterian Healthcare System, Santa Fe & Espanola, NM

Alexis M. LaPietra, DO; Department of EM; Saint Joseph’s Regional Medical Center; Paterson, NJ

Joshua J. Lynch, DO; Jacobs School of Medicine and Biomedical Sciences; Department of EM; University of Buffalo Buffalo, NY

Sergey Motov, MD; Department of EM, Maimonides Medical Center, Brooklyn, NY

Zachary Repanshek, MD; Department of EM, Lewis Katz School of Medicine, Temple University, Philadelphia, PA

Scott G. Weiner, MD, MPH; Department of EM, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA

Lewis S. Nelson, MD; Department of EM, Rutgers New Jersey Medical School, Newark, NJ

Questions Addressed

  1. How can emergency clinicians prevent the development of opioid use disorder in opioid-naive patients who present with acute pain?
  2. What is opioid withdrawal syndrome?
  3. Should patients with opioid withdrawal be treated with opioid agonist therapies or non-agonist therapies?
  4. How is OWS treated with agonists and/or non-agonists?
  5. How can emergency clinicians protect the health of OUD patients apart from initiating buprenorphine?
  6. What is the relative efficacy of MAT compared to abstinence-based treatment programs in reducing morbidity and mortality in patients with opioid use disorder?
  7. How do naltrexone, methadone, and buprenorphine compare as treatments for opioid use disorder?
  8. What are the pharmacologic features of buprenorphine that make it well-suited to treat opioid use disorder?
  9. What are the important harms associated with buprenorphine use and buprenorphine abuse?
  10. Which immediate release buprenorphine preparations are commonly used in acute care settings to treat opioid use disorder?
  11. What are the roles for buprenorphine mono-product and the combination product with naloxone?
  12. What long-acting forms of buprenorphine are available?
  13. Which buprenorphine preparation should be used in pregnancy?
  14. Is it necessary to have psychiatry or addiction specialists available for consultation in order to initiate buprenorphine in the ED?
  15. Is it necessary to have DATA 2000-waivered physicians in the ED in order to initiate buprenorphine?
  16. How robust must outpatient follow-up resources be in order to initiate buprenorphine in the ED?
  17. What other regulatory requirements pertain to ED-initiated buprenorphine?
  18. How should ED patients be screened for opioid use disorder?
  19. Which patients should be considered for ED-based buprenorphine initiation?
  20. In which patients should ED-based buprenorphine initiation be avoided, or used with particular caution?
  21. How can sufficient spontaneous (abstinence-induced) opioid withdrawal be assured, so that buprenorphine-precipitated withdrawal is avoided?
  22. What ancillary testing should be done prior to or during ED-initiated buprenorphine?
  23. How should emergency clinicians dose buprenorphine?
  24. How long should ED-initiated buprenorphine patients be observed and what adverse effects can occur?
  25. How can buprenorphine be initiated in patients not yet in sufficient withdrawal?
  26. How can buprenorphine be initiated in patients who have completed their period of physical withdrawal?
  27. How can buprenorphine be initiated in patients who decline buprenorphine in the ED?
  28. What is the appropriate disposition for patients treated with buprenorphine in the ED?
  29. Which patients discharged from the ED after buprenorphine initiation should receive a buprenorphine prescription?
  30. How can providers improve the likelihood that a patient will be able to fill a prescription for buprenorphine?
  31. What is the appropriate prescribed dose of buprenorphine?
  32. How can buprenorphine be prescribed for home initiation, for patients who do not receive buprenorphine in the ED?
  33. How should patients be linked to outpatient comprehensive addiction care?
  34. What discharge instructions should be given to patients initiated with buprenorphine in the ED?
  35. Should emergency clinicians use buprenorphine to treat OUD patients who are unwilling or unlikely to continue with long-term buprenorphine treatment or enter into outpatient addiction care?
  36. Should emergency clinicians use buprenorphine to treat OUD patients who in addition to opioids use sedatives such as alcohol or benzodiazepines, other recreational substances, or have concomitant psychiatric illness?
  37. Should emergency clinicians use buprenorphine to treat OUD patients who have been in buprenorphine treatment in the past, but have now returned to street or prescription opioid misuse?
  38. How should emergency clinicians counsel OUD patients (or their loved ones) who are concerned that buprenorphine therapy is ‘replacing one addiction with another’ or concerned about long-term buprenorphine use?
  39. How should buprenorphine-precipitated withdrawal be managed in the ED?
  40. How should emergency clinicians manage patients who have naloxone-precipitated withdrawal?
  41. How should prescription drug monitoring programs be used in emergency care?
  42. How should emergency clinicians manage patients maintained on buprenorphine who have acute pain from illness or injury?
  43. How should emergency clinicians manage acute moderate or severe pain in a patient with a history of opioid use disorder, now in abstinence recovery (not taking methadone or buprenorphine)?
  44. How should emergency clinicians treat exacerbations of chronic pain in patients who take daily prescription opioids?
  45. How should emergency clinicians manage pain at the end of life?
  46. How should emergency clinicians manage patients on methadone maintenance who have missed their usual methadone dose?
  47. How should emergency clinicians manage patients on methadone maintenance who have acute moderate to severe pain from intercurrent illness or injury?
  48. How can ED administrators encourage best practices related to opioid prescribing and reduction of opioid related harms?

Next Steps

The White Paper and references were approved by the AAEM Board of Directors on September 22, 2019 and will be published in the Journal of Emergency Medicine in the coming months.

Author: Bryan D. Hayes, PharmD

Attending Pharmacist, Emergency Medicine and Toxicology, Massachusetts General Hospital; Assistant Professor of EM, Harvard Medical School

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