Consensus Recommendations on the Treatment of Opioid Use Disorder in the Emergency Department

Abstract

The treatment of opioid use disorder with buprenorphine and methadone reduces morbidity and mortality in patients with opioid use disorder. The initiation of buprenorphine in the emergency department (ED) has been associated with increased rates of outpatient treatment linkage and decreased drug use when compared to patients randomized to receive standard ED referral. As such, the ED has been increasingly recognized as a venue for the identification and initiation of treatment for opioid use disorder, but no formal American College of Emergency Physicians (ACEP) recommendations on the topic have previously been published. The ACEP convened a group of emergency physicians with expertise in clinical research, addiction, toxicology, and administration to review literature and develop consensus recommendations on the treatment of opioid use disorder in the ED. Based on literature review, clinical experience, and expert consensus, the group recommends that emergency physicians offer to initiate opioid use disorder treatment with buprenorphine in appropriate patients and provide direct linkage to ongoing treatment for patients with untreated opioid use disorder. These consensus recommendations include strategies for opioid use disorder treatment initiation and ED program implementation. They were approved by the ACEP board of directors in January 2021.

Perspectives About Emergency Department Care Encounters Among Adults With Opioid Use Disorder

“…Some comments revealed specific opportunities to facilitate improved care for patients with OUD seen in the ED, including offering on-demand treatment and ED staff training on stigma, OUD, and OUD treatment. Given recent advances in resources and support for treating OUD in EDs 4 , 37 , 38 , 39 they should be capable of making these changes; however, implementation will require optimized training to reduce stigma and enhance care for patients with OUD.…”

Emergency department‐initiated buprenorphine protocols: A national evaluation

“…Although variation existed across the 31 protocols, most used a similar flow of patients from ED presentation to discharge. We therefore recommend the following evidence‐based framework (Figure 2 ), consistent with the recently released ACEP Consensus Recommendations on the Treatment of Opioid Use Disorder in the Emergency Department 56 : (1) identification of patients; (2) Assessment of OUD, withdrawal severity, and pregnancy; (3) treatment with buprenorphine initiation or instructions for unobserved (home) induction; and (4) discharge with overdose education and naloxone distribution, buprenorphine prescription, and referral for follow‐up care.…”

Guidance for emergency medicine pharmacists to improve care for people with opioid use disorder

“…Buprenorphine has the potential to displace other full opioid agonists from the mu-opiate receptor site, subsequently producing withdrawal symptoms. 3 To avoid precipitated withdrawal, it is important to assess the timing of the patient's last opioid use, the specific opioid's duration of action, and the presence of any current withdrawal symptoms.…”

“…17 However, the use of high-dose buprenorphine inductions (>12-32 mg) in the ED setting in an attempt to decrease the time to withdrawal symptom resolution and lengthen the duration of action until subsequent outpatient follow-up, has been explored and may become more common in the future. 3,30 Emergency Medicine Pharmacists may consider recommending this method for patients who may have significant barriers to follow-up and continued dosing. Recent evidence has also shown that buprenorphine induction could be considered shortly after naloxone administration in the setting of fentanyl or heroin overdoses.…”

“…Emergency Medicine Pharmacists (EMPs) can play a variety of integral roles in mitigating the impact of this epidemic including identification of patients affected by opioid use disorder (OUD), initiating drugs for opioid use disorder (MOUD) and harm-reduction practices, as well as facilitating connections to counseling and rehabilitation services after discharge (Figure 1). 1,3 They are also well-positioned to limit unnecessary opioid prescribing and prescription opioid misuse both within the ED and upon discharge through the implementation of opioid-stewardship programs, protocol development, as well as patient education regarding the safe use of opioid therapy. This article seeks to review the F I G U R E 1 Guidance for emergency medicine pharmacists to improve care for people with opioid use disorder multitude of ways in which EMPs can support efforts to improve the care of people with OUD on the frontlines.…”