PLEASE NOTE: THIS RESOLUTION WILL BE DEBATED AT THE 2015 COUNCIL MEETING. RESOLUTIONS ARE NOT
OFFICIAL UNTIL ADOPTED BY THE COUNCIL AND THE BOARD OF DIRECTORS (AS APPLICABLE).
RESOLUTION:
35(15)
SUBMITTED BY:
Pennsylvania College of Emergency Physicians
SUBJECT:
Emergency Department Detox Guidelines
PURPOSE: Create a clinical practice guideline on detoxification of patients presenting to the emergency
department in opioid or benzodiazepine withdrawal and create a practice resource to educate emergency providers
on opioid and benzodiazepine addiction.
FISCAL IMPACT: Budgeted committee and staff resources for a development of a clinical policy. Additional
expenses for literature searches, evidence grading, conference calls, and meeting expenses. Unbudgeted staff
resources for development of a practice resource on the science of addiction, in addition to expenses for
conference calls, research of topic, and a possible meeting.
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WHEREAS, Chronic pain affects 100 million Americans, about a third of the adult US population; and
WHEREAS, Chronic pain is the primary reason for disability in America1, and
WHEREAS, The number of opioid and benzodiazepine prescriptions for chronic pain has increased
dramatically; and
WHEREAS, There has been an increase in prescription drug abuse, accidental overdoses and need for
addiction treatment; and
WHEREAS, As “Pill Mills” are actively being targeted and shut down by the DEA, many opiate and
benzodiazepine dependent patients find themselves without medications and present to the emergency department
in withdrawal; and
WHEREAS, Opiate withdrawal can be painful, lead to abnormal behaviors, cause physical dehydration,
and other symptoms; and
WHEREAS, Benzodiazepine withdrawal can cause life threatening seizures, and
WHEREAS, Many communities have inadequate resources for patients requesting help with addiction to
prescription opiate and benzodiazepines and present themselves for treatment to the emergency department;
therefore be it
RESOLVED, That ACEP create clinical practice guidelines for detoxification of patients presenting to the
emergency department in opioid or benzodiazepine withdrawal; and be it further
RESOLVED, That ACEP create a practice resource to educate emergency providers about the science of
opioid and benzodiazepine addiction.
Reference
1
National Drug Intelligence Center. The Economic Impact of Illicit Drug Use on American Society. Washington, DC: United
States Department of Justice, 2011
Resolution 35(15) Emergency Department Detox Guidelines
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Background
This resolution asks the College to: 1) create a clinical practice guideline on detoxification of patients presenting
to the emergency department in opioid or benzodiazepine withdrawal; and 2) create a practice resource to educate
emergency providers on opioid and benzodiazepine addiction.
The primary author of the resolution, ACEP Pennsylvania Chapter President Todd Fijewski, MD, FACEP,
clarified that the resolution asks for help (tool kit, best practices, etc.) with the longer-term management of
individuals in active withdrawal from these medications. There has been a sharp increase in heavily addicted
patients presenting in active withdrawal after certain physician offices (“pill mills”) have been closed and those
physicians sent to prison for overprescribing these drugs. It is thought that the short-term treatment that is usual in
emergency medicine is not sufficient for patients who have no other health care provider and no community
resource to assist them through withdrawal.
The CDC notes that each day 44 people in the United States die from overdose of prescription painkillers, and
that opioids and benzodiazepines are commonly abused medications. Cities and states have made efforts to
combat the problem by regulating pain clinics, identifying fraudulent prescriptions, improving access to naloxone
for opioid overdose, and utilizing prescription drug monitoring programs. According to the CDC WONDER
online database, while the public health burden of this epidemic remains enormous, 2012 saw the first national
drop in prescription overdose deaths since the 1990s. Overdose deaths from opioid analgesics have essentially
leveled off or slightly declined since then. This drop in deaths mirrors a similar drop in painkiller prescribing rates
across the country. At the same time, heroin overdose deaths have increased sharply (CDC NCHS Data Brief,
#190, March 2015), indicating that success in reducing opioid availability may have an unintended consequence
of driving certain drug abusers to increasingly seek out heroin to feed their addiction.
Authors of a study in the August 2015 American Journal of Public Health noted that 38 states reported at least
75% of their opioid treatment programs were operating at 80% capacity or more. They concluded that significant
gaps between opioid abuse or dependence rates and potential buprenorphine treatment capacity exist at the state
and national levels, and that strategies to increase the number of opioid agonist medication-assisted treatment
providers are needed.
The Affordable Care Act extends the Mental Health Parity and Addiction Equity Act so that many health plans
must offer coverage for substance use disorders. Health insurers and government entities have an important role in
ensuring access to effective and accessible additional treatment services.
The Substance Abuse and Mental Health Services Administration (SAMHSA) has developed a toolkit for opioid
overdose that includes such things as provider information on treating opioid overdose and resources such as
physician and treatment program locators.
SAMHSA and the Center for Substance Abuse Treatment (CSAT) developed a Quick Guide for Clinicians
containing guidelines, tools, and resources on detoxification and substance abuse treatment.
The NIH National Institute on Drug Abuse and other Web sites offer information regarding the science of
addiction.
ACEP is part of the American Medical Association’s Task Force to Reduce Opioid Abuse. Goals of the Task
Force include: (1) enhancing physicians’ education on effective, evidence-based prescribing; (2) increasing
physicians’ use of effective prescription drug monitoring programs; (3) reducing the stigma of pain and promoting
comprehensive assessment and treatment; (4) reducing the stigma of substance use disorder and enhancing access
to treatment; and (5) expanding access to naloxone in the community and through co-prescribing.
ACEP Strategic Plan Reference
Promote quality and patient safety, including development and validation of quality measures.
Resolution 35(15) Emergency Department Detox Guidelines
Page 3
Promote federal and state legislative proposals that seek to reduce/eliminate prescription drug abuse and facilitate
appropriate treatment for those addicted to prescription opioids or illicit narcotics.
Fiscal Impact
Budgeted committee and staff resources for a development of a clinical policy. Additional expenses for literature
searches, evidence grading, conference calls, and meeting expenses. Unbudgeted staff resources for development
of a practice resource on the science of addiction, in addition to expenses for conference calls, research of topic,
and a possible meeting.
Prior Council Action
Amended Resolution 42(14) Reverse an Overdose, Save a Life adopted. Directed ACEP to advocate and support
the training and equipping of first responders to use injectable and nasal spray naloxone and for the availability of
naloxone being dispensed over the counter with overdose education by a pharmacist.
Amended Resolution 39(14) Naloxone Prescriptions by Emergency Physicians adopted. Directed ACEP to
develop a clinical policy on the clinical conditions for which it is appropriate for emergency physicians to
prescribe naloxone.
Amended Resolution 44(13) Prescription Drug Overdose Deaths adopted. Directed ACEP to review solutions to
decrease the death rate from prescription drug overdoses and create a document offering best practice solutions.
Resolution 39(13) Naloxone Prescriptions in the ED not adopted. Called for supporting and advising emergency
physicians to dispense and/or prescribe Naloxone for victims of opioid overdose treated in the ED and promote
the ability of emergency physicians to lawfully prescribe Naloxone explicitly for potential future opiate overdose
through legislative or regulatory advocacy.
Resolution 38(13) Naloxone as an Over the Counter Drug not adopted. Called for adoption of a policy statement
in support of Naloxone becoming available as an OTC drug and promote education and safeguards for its use.
Amended Resolution 21(12) Support of Non-Punitive Sobering Centers and Community Recovery Services
adopted. This resolution called for the College to explore the development of sobering centers, identify medical
and professional needs for these community centers, and promulgate efforts to support the development of these
entities.
Amended Resolution 17(12) Ensuring ED Patient Access to Adequate and Appropriate Pain Treatment adopted.
This resolution called for ACEP to oppose non-evidence based public or private limits on prescribing opiates,
mandatory opioid related documentation, and mandatory opioid related CME. Also to work with government and
regulatory bodies on the creation of evidence-supported guidelines for responsible emergency physician
prescribing that takes into consideration lack of access.
Resolution 16(12) Development of Guidelines for the Treatment of Chronic Pain not adopted. Called for support
for each state to establish guidelines for the treatment of patients with chronic pain, and noted that important in
the treatment is the establishment of a referral network to existing pain treatment centers that are better suited to
follow a patient’s narcotic prescriptions. Defeated
Prior Board Action
Amended Resolution 42(14) Reverse an Overdose, Save a Life adopted.
Amended Resolution 39(14) Naloxone Prescriptions by Emergency Physicians adopted.
October 2013, reviewed the report on Sobering Centers that was developed in response to Amended Resolution
21(12) Support of Non-Punitive Sobering Centers and Community Recovery Services. .
Resolution 35(15) Emergency Department Detox Guidelines
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Amended Resolution 44(13) Prescription Drug Overdose Deaths adopted
Amended Resolution 21(12) Support of Non-Punitive Sobering Centers and Community Recovery Services
adopted.
Amended Resolution 17(12) Ensuring ED Patient Access to Adequate and Appropriate Pain Treatment adopted.
June 2012, approved: “Clinical Policy: Critical Issues in the Prescribing of Opioids for Adult Patients in the
Emergency Department.”
Background Information Prepared by: Mary Anne Mitchell, ELS
Clinical Practice Manager
Rhonda Whitson, RHIA
Clinical Practice Manager
Reviewed By: Kevin Klauer, DO, EJD, FACEP, Speaker
James Cusick, MD, FACEP, Vice Speaker
Dean Wilkerson, JD, MBA, CAE, Council Secretary and Executive Director