American emergency medicine physicians have been taking measures to address the ongoing opioid crisis, which affects emergency departments (EDs) throughout the country, according to a clinical review article published in the Annals of Emergency Medicine. After assessing current ED protocols for dealing with patients diagnosed with or suspected of opioid use disorder (OUD), the investigators formulated 4 recommendations aiming to better identify individuals with OUD, treat acute withdrawal syndrome, implement medication-assisted therapy (MAT), and transition those affected to outpatient care.
The American opioid epidemic has affected EDs across the country, as they stand on the front lines, with clinicians routinely encountering abuse, overdose, withdrawal, and associated complications. Rather than focusing on ongoing efforts aiming to reduce opioid prescriptions and develop alternative analgesics, the authors of the review were interested in describing evidence-based best practices for the effective identification and management of individuals with OUD — with an emphasis on MAT when appropriate — as well as for the establishment of strong connections to outpatient support services for follow-up after patients leave the ED.
Efficient screening of patients with potential OUD or withdrawal is essential for successful diagnosis and treatment. Six screening tools were identified as being useful for initial evaluation, with a preference for the Revised Screener and Opioid Assessment for Patients with Pain (SOAPP-R) and the National Institute for Drug Abuse-Modified Alcohol, Smoking and Substance Involvement Screening Test (NIDA-m-ASSIST). In the absence of formal guidelines, the investigators endorsed targeted screening and recommended against universal screening, suggesting that use of these tools in conjunction with state prescription monitoring programs, where available, might be useful.
Opioid withdrawal in those not on long-term narcotic therapies should be treated with MAT (ie, buprenorphine or methadone, depending on patient history). Non-opioid medications such as clonidine should be used as necessary, along with supportive care with fluids and electrolytes. In addition, any patient with OUD should be considered for MAT while in the ED, preferably with buprenorphine, and everyone should be given a naloxone kit or a prescription for one, with instructions on how to use it. Before discharge, every effort should be made to rapidly transition patients with OUD to a community outpatient setting, ideally via a “warm handoff” that involves direct contact between ED staff and outpatient caregivers. Along with continued MAT, outpatients should receive psychological counseling and social services, in order to optimize treatment outcomes.
Opioid addiction/abuse undoubtedly remains a challenge for ED physicians and society at large. Future investigations should focus on identifying the most effective screening tools and technologies to be used in the fight against it, along with the proper selection of patients to be screened.
“A robust infrastructure to support, educate, and enable emergency physicians to manage opioid use disorder in an evidence-based fashion and rapidly transition care to outpatient services is a necessary step in turning the tide against an opioid epidemic affecting communities nationwide,” concluded the authors.
Duber HC, Barata IA, Cioè-Peña E, et al. Identification, management, and transition of care for patients with opioid use disorder in the emergency department. Ann Emerg Med. June 2018:1-12. doi:10.1016/j.annemergmed.2018.04.007