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Opioid Guideline: Prescribing for Pain Management and Use in the Emergency Department

Christina Mattina and Laura Joszt
The United States is in the midst of an opioid epidemic that has been responsible for a 200% increase in deaths due to overdose of heroin or an opioid pain reliever since 2000. Guidelines provide clinicians with ways to identify patients at risk of opioid use disorder and best practices of prescribing opioids.
Monitoring Patients on Opioids
Patients who are on chronic opioid therapy should be assessed periodically and monitored for pain intensity and level of functioning. The CDC recommends evaluating the benefits and harms within 1 to 4 weeks of initiating opioid therapy or escalating a dose.10 The first few days of initiating opioid treatment are critical, and the risk for overdose with prescriptions for extended-release/long-acting opioids (eg, methadone, transdermal fentanyl, oxycodone) is particularly high during the first 2 weeks of treatment.9 Follow-up within as little as 3 days might be appropriate when methadone is prescribed or the dosage of methadone is increased.
 
During these follow-ups, clinicians should inquire about progress toward functional goals, pain control, and [increased] quality of life, as well as [monitoring for] adverse effects or warning signs for overdose, such as sedation or slurred speech, or opioid use disorder, such as wanting to take opioids more frequently than prescribed or difficulty controlling use.9 During the follow-up, clinicians can assess the patient’s willingness to continue on opioid therapy. There are common adverse events that clinicians should be able to identify and treat:
  • Constipation
  • Nausea or vomiting
  • Sedation or clouded mentation
  • Hypogonadism and other hormonal deficiencies
  • Pruritus (severe itching)
  • Myoclonus (quick, involuntary muscle jerk)11
 
Continuing the use of opioid therapy for 3 months can increase the risk of opioid use disorder; therefore, clinicians should continue to evaluate the benefits and harms of therapy at least every 3 months.9 Regular monitoring is important because “therapeutic risks and benefits do not remain static and can be affected by changes in the underlying pain condition, presence of coexisting disease, or changes in psychological or social circumstances,” the American Pain Society and American Academy of Pain Medicine wrote in its 2009 opioid treatment guidelines.11 Per CDC recommendations, for the highest chance of preventing the development of an opioid use disorder, follow-up earlier than 3 months may be necessary in cases of continued opioid therapy.9
 
“Monitoring of compliance is a critical aspect of chronic opioid prescribing, using such tools as random urine drug screening, pill counts, and where available, review of prescription monitoring data base reports,” the American Academy of Pain Medicine released in a statement in 2013.12
 
Prescribing Opioids in the Emergency Department
The intended audience of these CDC guidelines is primary care clinicians who are treating patients with chronic pain, and although “some of the recommendations might be relevant for acute care settings or other specialists, such as emergency physicians,” those settings are not the focus of the report.9 Acute care practitioners are instead advised to consult resources like the emergency department (ED) prescribing guidelines from the American College of Emergency Physicians (ACEP).
The below guidelines are compiled from the following sources: Washington State Opioid Prescribing Guidelines, as summarized by the Emergency Medicine Patient Safety Foundation (EMPSF) Prescribing and Dispensing Opioids in the Emergency Department13; New York City Emergency Department Opioid Prescribing Guidelines14; Maryland Emergency Department Opioid Prescribing Guidelines15; ACEP’s Clinical Policy: Critical Issues in the Prescribing of Opioids for Adult Patients in the Emergency Department16; and American Academy of Emergency Medicine (AAEM) Emergency Department Opioid Prescribing Guidelines for the Treatment of Non-Cancer Related Pain.17
 
Determining Appropriateness of Situations for Prescribing Opioids
1. Consider short-acting opioids only if the severity of the pain is reasonably assumed to warrant their use, or if the pain is refractory to other analgesics.14,16 Opioids should always be a second-line treatment to other analgesics unless there is a clear indication for the use of opioids (eg, a patient with acute abdomen pain or a long bone fracture).17 Emergency physicians may also prescribe short-acting opioids for relief of acute musculoskeletal pain while considering the benefits and risks for the individual patient.16
2. Refrain from providing replacement prescriptions for lost, stolen, or destroyed medications.13,15,17 Alternatively, confirm with the treating physician the validity of lost, stolen, or destroyed prescriptions, and if considered appropriate, replace the prescription with only a 1- to 2-day supply.14
3. Generally, ED clinicians should not provide replacement doses of methadone for patients in a methadone treatment program.13 If the patient’s ED treatment has prevented them from obtaining a scheduled dose of methadone or buprenorphine, it may be acceptable to provide the dose after verifying with the treatment program.15
4. Low back pain and exacerbations of chronic pain should first be addressed with non-opioid analgesics, nonpharmacologic therapies, and/or referral to a pain specialist for follow-up.14,16,17 Avoid routinely prescribing opioids for acute exacerbation of chronic pain seen in the ED.16
 
Do Not Prescribe
1. The administration of intravenous and intramuscular opioids in the ED is discouraged.13
2. Long-acting, controlled-release, or extended-release opioids should not be prescribed in the ED.13-16
3. The administration of Demerol (meperidine) in the ED is discouraged, as it lowers the seizure threshold.13
4. Opioids should not be prescribed [in the ED] for patients taking benzodiazepines, sedative-hypnotic medications, and/or concurrent opioids.14,17
 
Before Prescribing
1. Use a validated screening tool to assess the patient’s history of substance abuse and risk for opioid misuse, abuse, or diversion.13-16
2. Use a prescription drug monitoring program for information on recent controlled substance prescriptions, which can help identify patients who are “doctor shopping” or at high risk for prescription opioid diversion.15-17
3. Maintain a list of local chemical dependency treatment resources so that any patient suspected of opioid abuse can be referred to treatment.14
4. Maintain a list of primary care clinics that patients with chronic pain should consult in the future instead of visiting the ED.14
 
Prescribing Guidelines
1. When prescribing opioids for acute pain or injury, prescribe only for a short course (eg, less than 3 days or 1 week)14-17 and minimal quantity (no more than 30 pills).13,15
2. When prescribing opioids for exacerbations of chronic pain, contact the patient’s primary opioid prescriber and prescribe only enough pills to last until that patient’s prescriber opens.13
3. Start with the lowest possible effective dose of opioid medication.14,16,17
 
Patient Interaction After Prescribing
1. Provide patients with information about the risks of opioid dependence, addiction, and overdose, as well as guidelines for safe storage and disposal. In particular, caution patients not to share their prescription with anyone and to avoid sedatives while taking opioid medication.14,15,17
2. Following ED treatment with opioids (particularly the parenteral form), consider an appropriate period of observation and monitoring before discharge.15
3. When writing a prescription for opioids in the ED, state that the patient is required to show government-issued photo ID to the pharmacy filling the prescription.13
4. EDs are encouraged to photograph and keep a record of patients who present for pain-related complaints but do not have a photo ID.13
 
Sharing Information with Other Medical Providers
1. Patients with chronic pain should have a single medical provider that prescribes all opioids.13 Refer patients seeking a refill of their chronic opioid prescription to their original treating clinician.15 ED providers prescribing opioids for acute exacerbation of a chronic condition should attempt to notify the patient’s primary medical provider of the visit and prescription.15
2. Share the patient’s ED visit history with other physicians via a health information exchange, if possible.13,15
3. Physicians should make pain treatment contracts with their patients and send them to local EDs.12 ED prescribers should honor these agreements whenever possible.16
4. EDs should use an ED care coordination program to consistently coordinate the care of patients who frequently visit the ED. This could be done by including an ED care plan in the patient’s electronic health record.13
 
General
1. The Emergency Medical Treatment and Labor Act requires by law that every ED patient must be evaluated. However, it does not require the use of opioids for pain, so providers should use their clinical judgment when prescribing such treatment in the ED.13,17
 


 
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