the Maine ACEP Position Statement RE

Emergency Department Opioid Prescribing Guidelines
A core mission of Emergency Care is to provide timely, safe and appropriate relief of
pain and suffering through the use of medications and other therapeutic techniques. All
interventions must balance the benefit against the potential harm to the individual and
their community. Emergency care providers must consider both the patient advocacy
driven increased emphasis upon analgesia with the prescription opioid misuse pandemic.
Emergency Departments should strive for a standardized pain management approach that
attempts to empower patient needs while removing barriers to timely, adequate pain relief.
These guidelines reflect consensus recommendations but are not a substitute for best
clinical judgment in individual cases. Emergency care providers as part of their ongoing
continuous medical education should receive training in proper opioid prescribing and
medication diversion prevention best practices.
Patients presenting to the Emergency Department are strongly encouraged to provide a
government issued photo ID such as a driver’s license. Emergency Departments are
encouraged to develop biometric tool to assist in the confirmation of patient identity.
The Emergency Department will establish protocols to streamline the administration of
pain-relieving measures for those patients with acute moderate to severe pain. These
protocols should be adopted and utilized by the entire care team, covering a broad range
of diagnoses and be used in conjunction with the overall best care of the patient.
Patients whom are already prescribed chronic opioids (including from a drug treatment
center) should provide the name of all prescribers and their dosing regimen to the ED
care team. ED care providers are encouraged to contact (care coordination) those
resources before altering the established regimen such as prescribing additional opioids.
For patients with chronic painful conditions, it is best that they receive all their pain
medications from a sole outpatient provider source obtained ideally at a single pharmacy.
ED care providers should assist patients in adhering to all the conditions (contract) set
forth by that outpatient provider which may include but is not limited to 1) regular and
random drug screens, 2) pill counts, 3) attendance at regularly scheduled follow-ups and
4) reporting of all controlled substance prescriptions obtained from other providers.
The Emergency Department will develop a specific strategy to manage patients who seek
medical care frequently (exceed thresholds) for painful conditions. Ideally this would
include oversight by a multidisciplinary team including case managers and outpatient
referral facility representatives.
ED providers should be knowledgeable regarding the pharmacology and physiology of
opioids including intoxication, dependency, tolerance, hyperalgesia and withdrawal. In
certain circumstances patients may require reversal agents. Bridging opioid therapy may
be needed to prevent the health-threatening effects of withdrawal (e.g. miscarriage).
When initiated by ED providers, care plans should be developed in collaboration with
local pain management specialists.
Maine ACEP supports the development of home-grown adaptations of these guidelines to
allow policy makers and providers to be utilize local resources.
In summary, the Emergency Department recognizes its duty to provide timely analgesia
while acknowledging the current pandemic of opioid prescription drug misuse.
(Adapted from Washington State ACEP ED Prescribing Guidelines)
In general, the Emergency Department will not refill or replace lost, stolen or destroyed
scripts or medications. The ED will not provide doses of methadone or buprenorphine for
missed appointment dispensation.
Acute exacerbations of non-cancer, non-palliative care chronic pain must be managed
individually but the use of parenteral opioids for long-term pain is discouraged. Longacting medications (methadone) and time-release formulations (fentanyl patch,
Oxycontin®) should not be prescribed for acute exacerbations of chronic pain.
As part of a system-wide compliance program, the ED may be participatory in the
collection of urine drugs of abuse screening with patient consent and ideally prior to the
administration of controlled substances.
In the management of painful conditions in the ED, care providers are encouraged to
access the prescription monitoring program (PMP), screen patients for likelihood risk of
opioid diversion (Risk Assessment Tool), obtain urine drugs of abuse screens when
appropriate and notify the patient’s chronic care providers of specific quantities of
controlled substances if prescribed.
The minimum amount of opioids should be prescribed that would be adequate for typical
pain relief until the patient next closest follow-up. Typically this should not exceed 30
tablets or 3-4 days supply. Opioids should only be used with non-pharmacological
interventions and adjunctive medication as appropriate.