Written by Clay Smith
This is an ACEP Clinical Policy statement to address four key questions about opioid use in the ED.
Why does this matter?
Drug related deaths are now more common than deaths due to motor vehicle crashes. Not only is addiction and overdose a problem, these medications have other side effects, such as nausea, constipation, and increased fall risk.
Addressing pain points
Here are the four questions addressed by this clinical policy.
1) In adult patients experiencing opioid withdrawal, is emergency department-administered buprenorphine as effective for the management of opioid withdrawal compared with alternative management strategies?
Level B recommendations: “When possible, treat opioid withdrawal in the ED with buprenorphine or methadone as a more effective option compared with nonopioid-based management strategies such as the combination of alpha2-adrenergic agonists and antiemetics.” Level C recommendations. “Preferentially treat opioid withdrawal in the ED with buprenorphine rather than methadone.”
Comment: Use of buprenorphine in a patient who does not yet have withdrawal (COWS <8) may precipitate withdrawal. Methadone, with its long half life, may lead to increased risk of respiratory depression if given in the ED and a patient resumes use of other opioids; it also prolongs the QT interval. Prescribing buprenorphine requires special training and the DEA X-waiver.
2) In adult patients experiencing an acute painful condition, do the benefits of prescribing a short course of opioids on discharge from the emergency department outweigh the potential harms?
Level C recommendations. “Preferentially prescribe nonopioid analgesic therapies (nonpharmacologic and pharmacologic) rather than opioids as the initial treatment of acute pain in patients discharged from the ED. For cases in which opioid medications are deemed necessary, prescribe the lowest effective dose of a short-acting opioid for the shortest time indicated.”
Comment: Emergency physicians are not the main drivers of prescriptions leading to subsequent abuse, but 1-5% of patients prescribed opioids in the ED may have prolonged use, depending on how much was prescribed at the initial visit. There are few painful conditions for which an opioid alternative is not as good, if not better, for pain control. Lest we go too far, there is a place for opioids for severely painful conditions, i.e. metastatic cancer, severe injuries, etc.
3) In adult patients with an acute exacerbation of non-cancer chronic pain, do the benefits of prescribing a short course of opioids on discharge from the emergency department outweigh the potential harms?
Level C recommendations. “Do not routinely prescribe opioids to treat an acute exacerbation of non-cancer chronic pain for patients discharged from the ED. Non-opioid analgesic therapies (non-pharmacologic and pharmacologic) should be used preferentially. For cases in which opioid medications are deemed appropriate, prescribe the lowest indicated dose of a short-acting opioid for the shortest time that is feasible.”
Comment: This is an easy area for us to improve – no opioid prescriptions for chronic pain flare-ups…period.
4) In adult patients with an acute episode of pain being discharged from the emergency department, do the harms of a short concomitant course of opioids and muscle relaxants/sedative-hypnotics outweigh the benefits?
Level C recommendations. “Do not routinely prescribe, or knowingly cause to be co-prescribed, a simultaneous course of opioids and benzodiazepines (as well as other muscle relaxants/sedative-hypnotics) for treatment of an acute episode of pain in patients discharged from the ED (Consensus recommendation).”
Comment: Overdose deaths are greater when opioids are combined with benzodiazepines or other sedatives. Just avoid this. Muscle relaxers are minimally effective, if at all, anyway.
Clinical Policy: Critical Issues Related to Opioids in Adult Patients Presenting to the Emergency Department. American College of Emergency Physicians Clinical Policies Subcommittee (Writing Committee) on Opioids. Ann Emerg Med. 2020 Sep;76(3):e13-e39. doi: 10.1016/j.annemergmed.2020.06.049.
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