Clinical Policy: Critical Issues Related to Opioids in Adult Patients Presenting to the Emergency Department (Executive Summary): Approved by the ACEP Board of Directors, June 24, 2020

Abstract

For the complete list of authors including the members of the American College of Emergency Physicians Clinical Policies Committee (Oversight Committee) and to read this ACEP clinical policy please go to: www.annemergmed.com. For the complete list of authors including the members of the American College of Emergency Physicians Clinical Policies Committee (Oversight Committee) and to read this ACEP clinical policy please go to: www.annemergmed.com. This clinical policy from the American College of Emergency Physicians addresses key issues in opioid management in adult patients presenting to the emergency department. A writing subcommittee conducted a systematic review of the literature to derive evidence-based recommendations to answer the below critical questions. For each question, a systematic literature search was performed, evidence was graded and synthesized, and recommendations were made based on the strength of the available data. 1.In adult patients experiencing opioid withdrawal, is emergency department (ED)-administered buprenorphine as effective for the management of opioid withdrawal compared with alternative management strategies? None specified. 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 α2-adrenergic agonists and antiemetics. Preferentially treat opioid withdrawal in the ED with buprenorphine rather than methadone.2.In adult patients experiencing an acute painful condition, do the benefits of prescribing a short course of opioids on discharge from the ED outweigh the potential harms? None specified. None specified. 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.3.In adult patients with an acute exacerbation of noncancer chronic pain, do the benefits of prescribing a short course of opioids on discharge from the ED outweigh the potential harms? None specified. None specified. Do not routinely prescribe opioids to treat an acute exacerbation of noncancer chronic pain for patients discharged from the ED. Nonopioid analgesic therapies (nonpharmacologic 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.4.In adult patients with an acute episode of pain being discharged from the ED, do the harms of a short concomitant course of opioids and muscle relaxants/sedative-hypnotics outweigh the benefits? None specified. None specified. 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). Translation of Classes of Evidence to Recommendation Levels Based on the strength of evidence grading for each critical question, the subcommittee drafted the recommendations and the supporting text synthesizing the evidence, using the following guidelines: Generally accepted principles for patient care that reflect a high degree of scientific clinical certainty (eg, based on evidence from 1 or more Class of Evidence I or multiple Class of Evidence II studies demonstrating consistent effects or estimates). Recommendations for patient care that may identify a particular strategy or range of strategies that reflect moderate scientific certainty (eg, based on evidence from 1 or more Class of Evidence II studies or multiple of Class of Evidence III studies demonstrating consistent effects or estimates). Recommendations for patient care that are based on evidence from Class of Evidence III studies or, in the absence of any adequate published literature, based on expert consensus. In instances where consensus recommendations are made, “consensus” is placed in parentheses at the end of the recommendation.