Managing Emergency Department Patients With Opioid Use Disorder (Substance Use Disorders CME)

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Delivery Method:	Online
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Publication Date: June 2024 (Volume 26, Number 6)

CME Credits: 4 AMA PRA Category 1 Credits™, 4 ACEP Category I credits, 4 AAFP Prescribed credits, and 4 AOA Category 2-B CME credits. CME expires 06/01/2027.

Specialty CME Credits:Included as part of the 4 credits, this CME activity is eligible for 4 Substance Use Disorders CME credits, subject to your state and institutional approval. This CME activity is eligible for 4 credit hours toward the United States Department Justice Drug Enforcement Administration Medication Access and Training Expansion (MATE) requirements.

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Peer Reviewers

Abstract

As the United States continues to grapple with the opioid crisis, emergency clinicians are on the front lines of managing patients with opioid use disorder. This issue reviews tools and best practices in emergency department management of patients with opioid overdose and opioid withdrawal, and how substance use history will inform treatment planning and disposition. As growing evidence shows that medications for opioid use disorder (MOUD)—buprenorphine, methadone, and naltrexone—can have lasting impacts on patients’ addiction recovery, strategies for assessing patient readiness for MOUD and overcoming barriers to emergency department initiation of these medications are reviewed. Newer approaches to buprenorphine dosing (high-dose, low-dose, home induction, and long-acting injectable dosing) are also reviewed.

Case Presentations

A 55-year-old man presents to the ED complaining of opioid withdrawal and is requesting methadone…

• The patient starts to raise his voice asking for the medication. His vital signs are normal.
• As you assess the patient for opioid withdrawal, he is pacing the room and reports experiencing chills, body aches, and abdominal cramping. The patient states that he feels very anxious.
• Physical examination reveals normal-sized pupils, rhinorrhea, and piloerection. You calculate a Clinical Opiate Withdrawal Scale (COWS) score of 12 and think to yourself: Can this patient be safely started on medication for opioid use disorder, and if so, should I give methadone or offer another medication?

A 32-year-old woman is brought to your ED by EMS and is being ventilated with a bag-valve mask…

• The paramedics report that there was drug paraphernalia at the scene. They state that they found the patient to be apneic with pinpoint pupils, and despite administration of 4 mg of intranasal naloxone she continues to have poor respiratory effort.
• What are your next steps? Are there any adulterants that could exacerbate an opioid toxidrome?

A 46-year-old patient complaining of nausea and body aches is triaged to your team…

• When you speak with them, they report that they receive 100 mg of oral methadone daily for opioid use disorder (OUD), and their last dose was yesterday morning.
• You recently learned about using buprenorphine as treatment for OUD. You wonder whether the patient would be more satisfied with a 30-day prescription of buprenorphine rather than having to visit a methadone clinic daily. Can patients on methadone be safely transitioned to buprenorphine without precipitating withdrawal?

Accreditation:

EB Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.