Opioid Use Disorder Treatment in the EMERGENCY DEPARTMENT
SEMINAL STUDY
9.6
9.5 // Screening & Treatment in the ED
10.1 // Understanding Disparities in Rural Health
9 BEHAVIORAL HEALTH
Disclosures
No relevant disclosures or conflicts of interest to disclose
Learning objective
Implement evidence-based and society-endorsed best practices for patients seeking treatment or at risk of complications for substance use disorders, including ED initiation/provision of medications for opioid use disorder in appropriate patients and effective connection to longitudinal treatment
Best practices for opioid use disorder treatment
Despite the ongoing opioid overdose crisis—driven by fentanyl analogs and exacerbated by the COVID pandemic—a gap between evidence-based treatment and practice persists
Similar to acute MI, stroke, and trauma, EDs can advance the quality of timely care for patients with opioid overdose and withdrawal
As with newly diagnosed hypertension and diabetes, ED providers can initiate therapy for opioid use disorder (OUD) and link patients to treatment
Best practices for opioid use disorder treatment
Medications for opioid use disorder (MOUD)—specifically methadone and buprenorphine—reduce all-cause and opioid-specific mortality, nonfatal overdose, and infectious complications
ED-initiated buprenorphine reduces illicit opioid use and increases treatment engagement
Buprenorphine is the preferred treatment for adult ED patients with opioid withdrawal (ACEP), and is more cost-effective than referral alone
Best practices for opioid use disorder treatment
Identify clinical champions to support ED-initiated buprenorphine treatment
Integrate screening programs, treatment algorithms, and referral pathways into the electronic health record
Partner with community-based or telehealth programs to provide longitudinal treatment after ED discharge
Provide take-home naloxone, fentanyl test strips, and other harm reduction interventions
Best practices for opioid use disorder treatment
Avoid stigmatizing language (e.g., “addict,” “clean/dirty”)/use person-first language
Integrate the Brief Negotiation Interview—getting permission to discuss drug use, offering feedback motivation based on patients’ reasons to change—into the EHR
Given the risks of untreated OUD, buprenorphine should not be withheld from patients taking other CNS depressants (e.g., benzodiazepines)
Best practices for opioid use disorder treatment
Provide direct referral, ideally with specific date/time (warm handoff) or referral to bridge clinic
If no provider, consider SAMHSA treatment finder website
ED health navigators may improve outcomes
Include OUD diagnosis in chart using DSM-V criteria
Integrate decision support into EHR
Medications for opioid use disorder
The mu-opioid receptor antagonist naltrexone is typically impractical for ED use as it requires 7-10 days of opioid abstinence, and is less effective at reducing mortality in OUD
Methadone—a full mu-opioid receptor agonist—must be dispensed by federally licensed opioid treatment programs but can be initiated in the ED prior to referral
The partial mu-opioid receptor agonist buprenorphine can be prescribed from the ED (the X-waiver is no longer required), and has a ceiling on respiratory depression
ED protocols for initiating buprenorphine
Start 8-16 mg buprenorphine SL when signs of uncomplicated opioid withdrawal occurs, e.g., with ≥ 2 objective criteria (e.g., vomiting, piloerection) or score ≥ 8 on the Clinical Opioid Withdrawal Scale (COWS); may repeat in one hour
Onset of withdrawal typically >12 hours after short-acting opioids (except fentanyl) and variable after use of fentanyl or methadone (may be >72 hours)
Identify complicating factors (e.g., pregnancy, comorbidities, sedative use, DKA, sepsis)
ED protocols for initiating buprenorphine
Prescription to bridge to outpatient follow-up (e.g., buprenorphine/naloxone 8/2 mg SL 2-4/day) along with take-home naloxone
For patients not in opioid withdrawal, can discharge with instructions to start with 8 mg once severe symptoms occur (“self-start”)
See cabridge.org for high-dose, post-naloxone reversal, and microdosing protocols
ED treatment of precipitated withdrawal
Sudden severe withdrawal may occur after buprenorphine or full antagonist (e.g., naloxone or naltrexone)
Treat initially with buprenorphine 16 mg SL and repeat after 30-60 minutes
If unresolved may consider clonidine, haloperidol, high potency opioids (e.g., fentanyl), or ketamine
Special populations
Pregnancy: can safely use buprenorphine formulations with or without naloxone
May prescribe buprenorphine to adolescents with OUD ages 16 or over (though local policies may apply)
Consider adjusting dosing in elderly patients
Stigmatizing language
Stigma is a barrier to emergency department patients seeking OUD care—use person-first language, avoiding negative associations
Instead of… | Use… |
Addict, user, abuser, junkie | Person with a substance use disorder Person who uses drugs |
Alcoholic, drunk | Person with an alcohol disorder Person with hazardous alcohol use |
Clean or dirty | Toxicology: testing negative Non-toxicology: Being in remission or recovery, not actively using drugs, or not drinking |
Medication-assisted treatment or Opioid substitution replacement therapy | Medication for a substance use disorder Medication for opioid use disorder (MOUD) Pharmacotherapy |
ED distribution of naloxone
Community-based overdose education and naloxone education reduces opioid overdose death rates
ED take-home naloxone programs are feasible and acceptable to patients and providers
Take-home naloxone improves dispensing when compared to prescribing alone, and may decrease return visits for opioid overdose
ED take-home naloxone kit
Example kit including naloxone brochure, pharmacy access card, bag with patient label and QR code for instructional video, naloxone nasal spray (2-pack), CPR face shield, and nitrile gloves
OUD and pain management
Non-pharmacological treatments (e.g., ice, splinting)
Non-opioid pharmacological treatments: acetaminophen, NSAIDs, ketamine
Regional anesthesia
Buprenorphine and methadone can be continued for surgery (naltrexone must be held 72 hours)
OUD and pain management
Add short-acting full agonist (higher dosing than for opioid-naïve patients)
Increasing (20-25%) and/or splitting buprenorphine dosing (3-4/day) to bolster analgesic effect
Naltrexone may be overcome with high-potency full opioid agonists
Assessment questions
A 28 year-old G3P2 at 24 weeks gestation presents requesting treatment for OUD. They last injected fentanyl 2 hours prior and are awake and alert. After clinical evaluation and counseling, which is the most appropriate ED treatment?
Assessment questions
A 28 year-old G3P2 at 24 weeks gestation presents requesting treatment for OUD. They last injected fentanyl 2 hours prior and are awake and alert. After clinical evaluation and counseling, which is the most appropriate ED treatment?
Assessment questions
Which of the following is true regarding ED-initiated buprenorphine?
Assessment questions
Which of the following is true regarding ED-initiated buprenorphine?
References
Chua, K. P., Nguyen, T. D., Zhang, J., Conti, R. M., Lagisetty, P., & Bohnert, A. S. (2023). Trends in Buprenorphine
Initiation and Retention in the United States, 2016-2022. JAMA, 329(16), 1402-1404.
https://doi.org/10.1001/jama.2023.1207
Samuels, E. A., D'Onofrio, G., Huntley, K., Levin, S., Schuur, J. D., Bart, G., Hawk, K., Tai, B., Campbell, C. I., & Venkatesh, A. K. (2019). A Quality Framework for Emergency Department Treatment of Opioid Use Disorder. Ann Emerg Med, 73(3), 237-247. https://doi.org/10.1016/j.annemergmed.2018.08.439
Larochelle, M. R., Bernson, D., Land, T., Stopka, T. J., Wang, N., Xuan, Z., Bagley, S. M., Liebschutz, J. M., & Walley, A. Y. (2018). Medication for Opioid Use Disorder After Nonfatal Opioid
Overdose and Association With Mortality: A Cohort Study. Ann Intern Med, 169(3), 137-145. https://doi.org/10.7326/M17-3107
D'Onofrio, G., O'Connor, P. G., Pantalon, M. V., Chawarski, M. C., Busch, S. H., Owens, P. H., Bernstein, S. L., & Fiellin, D. A. (2015). Emergency department-initiated
buprenorphine/naloxone treatment for opioid dependence: a randomized clinical trial. JAMA, 313(16), 1636-1644. https://doi.org/10.1001/jama.2015.3474
D'Onofrio, G., McCormack, R. P., & Hawk, K. (2018). Emergency Departments - A 24/7/365 Option for Combating the Opioid Crisis. N Engl J Med, 379(26), 2487-2490.
https://doi.org/10.1056/NEJMp1811988
American College of Emergency Physicians Clinical Policies Subcommittee on, O., Hatten, B. W., Cantrill, S. V., Dubin, J. S., Ketcham, E. M., Runde, D. P., Wall, S. P., & Wolf, S. J. (2020). Clinical Policy: Critical Issues Related to Opioids in Adult Patients Presenting to the Emergency Department. Ann Emerg Med, 76(3), e13-e39. https://doi.org/10.1016/j.annemergmed.2020.06.049
Hawk, K., Hoppe, J., Ketcham, E., LaPietra, A., Moulin, A., Nelson, L., Schwarz, E., Shahid, S., Stader, D., Wilson, M. P., & D'Onofrio, G. (2021). Consensus Recommendations on the
Treatment of Opioid Use Disorder in the Emergency Department. Ann Emerg Med, 78(3), 434-442. https://doi.org/10.1016/j.annemergmed.2021.04.023
Hawk, K., Grau, L. E., Fiellin, D. A., Chawarski, M., O'Connor, P. G., Cirillo, N., Breen, C., & D'Onofrio, G. (2021). A qualitative study of emergency department patients who survived an
opioid overdose: Perspectives on treatment and unmet needs. Acad Emerg Med, 28(5), 542-552. https://doi.org/10.1111/acem.14197
�Church, B., Clark, R., Mohn, W., Potee, R., Friedmann, P., & Soares, W. E., 3rd. (2022). Methadone Induction for a Patient With Precipitated Withdrawal in the Emergency Department: A Case Report. J Addict Med. https://doi.org/10.1097/ADM.0000000000001109
Walley, A. Y., Xuan, Z., Hackman, H. H., Quinn, E., Doe-Simkins, M., Sorensen-Alawad, A., Ruiz, S., & Ozonoff, A. (2013). Opioid overdose rates and implementation of overdose education and nasal naloxone distribution in Massachusetts: interrupted time series analysis. BMJ, 346, f174. https://doi.org/10.1136/bmj.f174
Dwyer, K., Walley, A. Y., Langlois, B. K., Mitchell, P. M., Nelson, K. P., Cromwell, J., & Bernstein, E. (2015). Opioid education and nasal naloxone rescue kits in the emergency department. West J Emerg Med, 16(3), 381-384. https://doi.org/10.5811/westjem.2015.2.24909
Dora-Laskey, A., Kellenberg, J., Dahlem, C. H., English, E., Gonzalez Walker, M., Brummett, C. M., & Kocher, K. E. (2022). Piloting a statewide emergency department take-home naloxone program: Improving the quality of care for patients at risk of opioid overdose. Acad Emerg Med, 29(4), 442-455.
https://doi.org/10.1111/acem.14435
Samuels, E. A., Baird, J., Yang, E. S., & Mello, M. J. (2019). Adoption and Utilization of an Emergency Department Naloxone Distribution and Peer Recovery Coach Consultation Program. Acad Emerg Med, 26(2), 160-173. https://doi.org/10.1111/acem.13545
Samuels, E. A., Bernstein, S. L., Marshall, B. D. L., Krieger, M., Baird, J., & Mello, M. J. (2018). Peer navigation and take-home naloxone for opioid overdose emergency department patients: Preliminary patient outcomes. J Subst Abuse Treat, 94, 29-34. https://doi.org/10.1016/j.jsat.2018.07.013
American Society of Addiction Medicine (ASAM), 2020. National Practice Guideline 2020 Focused Update. Retrieved May 8, 2023 from https://www.asam.org/quality-care/clinical-guidelines/national-practice-guideline
National institute on Drug Abuse (NIDA), 2021. Words Matter - Terms to Use and Avoid When Talking About Addiction. NIH. Retrieved May 8 from https://nida.nih.gov/nidamed-medical-health-professionals/health-professions-education/words-matter-terms-to-use-avoid-when-talking-about-addiction
SEMINAL STUDY
Understanding Disparities in Rural Health
10.1
10.2 // Rural EM Clinical Practice
10.3 // Rural EM Workforce
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