Opioid Prescribing in the ED
Many patients seeking care in the emergency department (ED) present with severe pain, which may be due to an acute or chronic condition. A primary goal of emergency care is to alleviate pain quickly, safely, effectively, and compassionately. Opioid medications remain the mainstay for treatment of severe pain.
However, the tragic results of misuse and abuse of opioids are seen all too frequently in the ED. The number of deaths related to the misuse and abuse of opioid medications has reached what has been called epidemic proportions. Federal and state government agencies, healthcare institutions, and practitioners have all worked to develop a variety of solutions to this problem. Prescription drug monitoring programs (PDMPs),better patient assessment tools, prescribing guidelines (or rules), patient educational materials, pain contracts or care plans, and freer access to naloxone have all been used in an effort to curb deaths from opioid abuse.
Treatment of chronic pain with long-acting opioid medications is a primary driver of the opioid epidemic, made worse by the aging population. Misuse and diversion of these medications is a serious problem, but significant numbers of these agents are rarely prescribed from the ED.
It is important for emergency physicians to understand that while they are not the primary cause of the opioid abuse epidemic, they do have a role to play in fighting it. Because of the patient population they treat, emergency physicians are frequent prescribers of opioids, and thus may become targets for over-zealous regulators.
It is incumbent upon emergency physicians to be active participants in the quest for solutions, to always remain a strong advocate for their patients, and to adapt their practices to this new societal reality.
With better assessment tools, we can identify patients at risk for substance abuse.
By using PDMPs, we can identify patients that might be doctor shopping.
By using reasonable prescribing guidelines, we can limit the number of opioids in society, while adequately addressing the legitimate pain relief needs of our patients.
With better educational tools, we can help patients understand the proper use (and potential for misuse or diversion) of these medications.
Facilities that use care plans and pain contracts and that have treatment facilities can improve patient care.
Patient education regarding opioids can be a sensitive issue and must occur only after the patient is assessed. Posters in the waiting room are to be avoided because they could be perceived as discouraging patients from seeking emergency care. It is important to educate patients on this subject, but only after they have received a medical screening examination consistent with the Emergency Medical Treatment & Labor Act (EMTALA) regulations.
The resources contained in this document were compiled to provide background information, educational resources, patient handouts, and case management materials regarding opioid prescribing in the ED, with an emphasis on EMTALA-compliant patient education materials.
Reference Materials for Emergency Department Staff
Scope of the Problem
Centers for Disease Control and Prevention (2014). Fact Sheet: Prescription Drug Overdose in the US.
Centers for Disease Control and Prevention (2014). Vital Signs: Variations Among States in Prescribing of Opioid Pain Relievers and Benzodiazepines –United States, 2012.
Centers for Disease Control and Prevention (2011). Vital Signs: Prescription Painkiller Overdoses in the US.
National Institute on Drug Abuse (2014). Prescription Drugs & Cold Medicines.
Substance Abuse and Mental Health Services Administration (2013). The DAWN Report. Highlights of the 2011 Drug Abuse Warning Network (DAWN) Findings on Drug-Related Emergency Department Visits.
ED Pain Management
Emergency Medicine Patient Safety Foundation (2013). Prescribing and Dispensing Opioids in the Emergency Department. This article looks at the safety of opioid therapy and provides an overview of the Washington State opioid prescribing guidelines and additional recommendations.
Kuehn BM. CDC: Major disparities in opioid prescribing among states - Some states crack down on excess prescribing. JAMA. 2014:312(7):684-686. Article highlights state-specific data on opioidprescribing, legislative efforts, and the impact of these efforts.
AHRQ Health Care Innovations Exchange. Cross Agency Mayoral Task Force Promotes Policies and Initiatives to reduce opioid misuse and related problems, achieves some early successes. March 2014.
Be Aware: State Opioid Prescribing Regulations. Robert Broida, MD, FACEP.
Letter to Ohio Department of Health (September 2012) from Robert Broida, MD, FACEP re: Misuse of Statistics.
CMS Letter to South Carolina Hospital Association. 2013.
CMS Atlanta CMO response to EMTALA / Opioid signage inquiry. 2013.
US Food and Drug Administration. Consumer Health Information Q&A. Combating misuse and abuse of prescription drugs. July 2010.
Bitterman RA. Is “severe pain” considered an emergency medical condition under EMTALA? ACEP Now, April 2013. This article addresses misconceptions about the treatment of severe pain and what is required under EMTALA.
American College of Emergency Physicians. Clinical policy: Critical issues in the prescribing of opioids for adult patients in the emergency department. Ann Emerg Med. 2012;60:499.525.
Washington Emergency Department Opioid Prescribing Guidelines.
New York City Emergency Department Discharge Opioid Prescribing Guidelines.
Ohio Emergency and Acute Care Facility Opioids and Other Controlled Substances (OOCS) Prescribing Guidelines.
Medical Society of Delaware. MSD Guidelines for the Use of Controlled Substances for the Treatment of Pain. April 2013. Guidelines include the treatment of pain in the ED.
Pennsylvania Guidelines on the Use of Opioids to Treat Chronic Noncancer Pain. July 2014.
California Medical Board. Guidelines for Prescribing Controlled Substances for Pain (2007).
Prescription Drug Monitoring Programs
AHRQ Innovations Exchange. System Gives Authorized Users Access to Interstate Information on Controlled Substance Prescriptions Assisting Them in Identifying Cases of Potential Misuse. The National Association of Boards of Pharmacy (NAPB) Prescription Monitoring Program (PMP) InterConnect is a data exchange platform that links PMPs that allow authorized prescribers and dispensers to access patient-specific informa
US Department of Justice: Office of Diversion Control. State Prescription Drug Monitoring Programs Q & A (2011)
Drug Abuse Warning Network (DAWN). DAWN is a public health surveillance system that monitors drug-related hospital ED visits.
The Joint Commission Sentinel Event Alert. Safe use of opioids in hospitals (2012)
SAMHSA Opioid Overdose Toolkit: Information for Prescribers. The toolkit provides information on patient assessment, use of state PDMPs, treatment agreements, safeguards before prescribing, naloxone prescription consideration, overdoses, liability, and prescriber resources.
Patient Education Handouts
General Instructional Materials
Narcotic prescribing instructions
Prescribing Pain Medication in the ED. Patient educational information approved by the ACEP Board of Directors for distribution to the patient after the medical screening exam.
ED Waiting Room Posters on Prescribing Pain Medications May Violate EMTALA. This article includes a statement from CMS region 4 office on the use of “pain” posters in the ED. ACEP Now. January 2014
SAMHSA. Opioid Overdose Toolkit: Information for Prescribers. The toolkit provides information on patient assessment, use of state prescription drug monitoring programs (PDMPs), treatment agreements, safeguards before prescribing, naloxone prescription consideration, overdoses, liability, and prescriber resources.
SAMHSA. Opioid Overdose Toolkit: Facts for Community Members, Safety Advice for Patients & Family Members Recovering from Opioid Overdose.
Case Management Materials
Sample Chronic Pain Contracts: Links to two pain contracts that address the use of the emergency department and the agreement with the primary care physician.
Your Pain Treatment Agreement. The pain treatment agreement documents the understanding between the patient and the prescriber. An example of a pain treatment agreement is provided.
Safe Opioid Prescribing PCSS-O: iPhone App: Evidence-based resources that are currently available to clinicians on the safe and effective use of these medications. Offers multiple resources related to opioid prescribing and the diagnosis and management of opioid use disorders including treatment agreements, tools to assess pain level, and links to guidelines. Sponsored by the American Academy of Addiction Psychiatry with support from SAMHSA.
Project Lazarus. A community-based public health program based on the premise that drug overdose deaths are preventable. The program based on prevention and opioid safety was developed and implemented in North Carolina, an area with a higher than average overdose death rate. The program includes resources for overdose survivors, patients, medical personnel, and legal considerations.
Chronic Opioid Treatment
SAMHSA. Managing Chronic Pain in Adults With or in Recovery from Substance Use Disorders: A Treatment Improvement Protocol. SAMHSA Tip 54. Addresses assessment, treatment plan development, functional impairment, and psychological symptoms and monitoring for relapse.
AHRQ Health Care Innovations Exchange. Multifaceted Program Featuring Guideline, Training, and Incentives Reduces Prescribing of High-Dose Opioid Therapy in Patients with Chronic Pain. State guidelines were used as a framework for this work.
Chou R, Fanciullo GJ, Fine PG. Clinical guidelines for the use of chronic opioid therapy in chronic noncancer pain. J Pain. 2009;10(2):113-130.
Chen LL. What do we know about opioid-induced hyperalgesia? J Clin Outcome Manage. 2014;21(3):169-175. This article reviews the literature on opioid-induced hyperalgesia (OIH), a condition caused by exposure to opioids to treat pain resulting in the patient’s becoming more sensitive to painful stimuli. OIH and opioid tolerance can reduce treatment efficacy. The article concludes that while the OIH phenomenon has been documented for over 2 decades, the clinical characteristics and mechanisms are not fully determined.
Safe and Effective Opioid Prescribing for Chronic Pain. Site sponsored by the Boston University School of Medicine with support from SAMHSA, this site presents course modules on prescribing opioids for chronic pain. CME credits available.
SAMHSA. NationalSurvey of Substance Abuse Treatment Services. This SAMHSA publication presents 2011 surveydata on public and private treatment facilities in all 50 states includinglocation and client and facility characteristics.
Resources gathered by members of the ACEP Emergency Medicine Practice Committee
Jennifer L. Wiler, MD, MBA, FACEP, Chair
Robert I. Broida, MD, FACEP, Subcommittee Chair
Wayne S. Barry, MD, FACEP
Enrique R. Enguidanos, MD, FACEP
Dan Freess, MD
Stuart Kessler, MD, FACEP
Alexis M. LaPietra, DO (ad hoc)
Anthony Mazzeo, MD, FACEP
Thomas B. Pinson, MD, MBA, FACEP
Kevin Reed, MD, FACEP
Mark Rosenberg, DO, MBA, FACEP
Brent Treichler, MD, MMM, FACEP
Michael A. Turturro, MD, FACEP
Patrick Um, MD, FACEP
Daniel R. Wehner, MD, FACEP
Michael J. Zappa, MD, FACEP