Critical Issues Related to Opioids in Adult Patients Presenting to the Emergency Department

Official 2020 guideline from the American College of Emergency Physicians.

Strength

Emergency Department

Opioid Withdrawal

Level B

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 ⍺2- adrenergic agonists and antiemetics.

Level C

Preferentially treat opioid withdrawal in the ED with buprenorphine rather than methadone.

Disposition

Acute Pain Episode

Level C

Preferentially prescribe nonopioid analgesic therapies (nonpharmacologic and pharmacologic) rather than opioids as the initial treatment of acute pain in patients discharged from the ED.

Level C

For cases in which opioid medications are deemed necessary, prescribe the lowest effective dose of a shortacting opioid for the shortest time indicated.

Level C

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).

Chronic Pain Exacerbation

Level C

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.

Level C

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.

Literature

Original/Primary Reference

Hatten BW, Cantrill SV, et al. Clinical Policy: Critical Issues Related to Opioids in Adult Patients Presenting to the Emergency Department. Ann Emerg Med. 2020;76(3):e13-e39.

Summary By

Eric Steinberg, DO, MEHP

What do the ratings mean?

Level A

Generally accepted principles for patient management that reflect a high degree of clinical certainty (ie, based on strength of evidence Class I or overwhelming evidence from strength of evidence Class II studies that directly address all of the issues).

Level B

Recommendations for patient management that may identify a particular strategy or range of management strategies that reflect moderate clinical certainty (ie, based on strength of evidence Class II studies that directly address the issue, decision analysis that directly addresses the issue, or strong consensus of strength of evidence Class III studies).

Level C

Other strategies for patient management that are based on Class III studies, or in the absence of any adequate published literature, based on panel consensus.