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CHAPTER 292:  Substance Use Disor ders      1959 Long-term treatment of all eating disorders requires a multidisciplinary approach, including psychotherapy, dietary interventions, and pharmacotherapy in certain cases. 63 If pharmacotherapy is indicated, it should be initiated by a psychiatrist or primary care provider. SPECIAL POPULATIONS  PREGNANT WOMEN Pregnancy can be a stressful time for a woman with an eating disorder, particularly with respect to maintaining adequate weight gain. There are conflicting data on whether the presence of eating disorders increases the risk of complications. The broadest study of its kind revealed that the majority of patients with anorexia and bulimia have normal pregnancies and healthy babies with, however, an increased risk of birth by cesarean section and an increased risk of postpartum depression. These differences remained between groups who had active symptoms and those with history of an eating disorder who were asymptomatic during pregnancy.  MEN Do not neglect the possibility of eating disorders in men. Men may account for between 10% and 25% of cases of anorexia and bulimia, 69 and binge eating is more prevalent in men than both anorexia and bulimia. The exact proportion of men with eating disorders is unknown because men are less likely to be diagnosed. Eating disorders in males are typically characterized by the drive to add muscle bulk and lean mass and are often associated with antecedent obesity, athletic performance concerns, bullying, and occasionally (but not always) sexual abuse. Men with eating disorders are more likely to abuse steroids and growth hor mones, particularly when muscle dysmorphia is present. REFERENCES The complete reference list is available online at www.TintinalliEM.com. the initiation of heroin use and that other factors are contributing to the increase in the rate of heroin use and related mortality. ” The scope of substance use disorders (SUDs) includes unhealthy use of alcohol, use of illicit drugs, and nonmedical use of prescription drugs. Severe SUDs resemble asthma, diabetes, hypertension, and other chronic diseases in that they have genetic components and patients have problems with adherence to medication, loss to follow-up, exacerbations, repeat visits to the ED, and hospital admissions. 9 Nevertheless, only a small fraction of those needing alcohol or drug treatment actually receive indicated therapy, compared with a much higher fraction of patients with chronic medical conditions. 10 This understanding of addiction as a chronic, relapsing medical condition requires us to shift our focus toward providing linkage to ongoing integrated treatment and community support services as an addition to acute care. 11 The gap in SUD treatment also reflects the impact of social stigma on disparities in availability, accessibility, and affordability of services. Language is powerful, especially when talking about substance use because stigma perpetuates negative perceptions, discourages use of treatment services, and contributes to further substance use. Words do matter and the language used to discuss addiction is important to decrease stigma (Table 292-1).

ility of services. Language is powerful, especially when talking about substance use because stigma perpetuates negative perceptions, discourages use of treatment services, and contributes to further substance use. Words do matter and the language used to discuss addiction is important to decrease stigma (Table 292-1). 12-14 UNHEALTHY ALCOHOL USE The term unhealthy alcohol use describes a spectrum of alcohol con sumption ranging from “risky” or hazardous use (no consequences experienced), to harmful use (experience of consequences), to what was previously called alcohol dependence but is now termed mild, moderate, or severe alcohol use disorders in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition classification. 15 The National Institute on Alcohol Abuse and Alcoholism defines low-risk drinking as follows: for men, no more than 14 drinks per week and no more than four drinks over a 2-hour occasion. Women of all ages and men >65 years old are advised to drink no more than seven drinks per week and no more than three drinks over a 2-hour occasion, because of gender and age differences in volume distribution and concentrations of alcohol dehydrogenase in the liver. Binge drinking (drinking too much too fast) is alcohol consumption that results in a blood alcohol level over the U.S. legal limit of 0.08 gram/dL, which for the average male is the result of more than four drinks in 2 hours and for the average female is more than three drinks in 2 hours. Nearly 32 million adults engage in extreme binge drinking, described as consuming two or more times these thresholds. 16 Abstinence is advised for pregnant women and underage drinkers, and a lower limit or absti nence is advised for patients with chronic conditions exacerbated by alcohol or who are taking medications with an alcohol interaction. Those who begin drinking before age 15 have a fourfold increased risk of developing dependence than those who begin drinking later. 18 Early onset also predicts adverse health status. 1 Underage drinking and drug use have a profound impact on the developing nervous system, CHAPTER Substance Use Disorders Kathryn Hawk Elizabeth A. Samuels Scott G. Weiner Gail D’Onofrio Edward Bernstein INTRODUCTION AND EPIDEMIOLOGY In EDs around the world, on every shift, patients present for medical conditions related to the consequences of unhealthy drinking or drug use. The World Health Organization reported in 2012 that 5.9% of all global deaths (3.3 million people) were attributed to the consumption of alcohol. 1 From 2006 to 2014, ED alcohol-related visits increased in the United States from 827,100 to 1.46 million. 2,3 In 2015, an estimated 29.5 million people, or 0.6% of the global adult population, qualified for a drug use disorder, yet fewer than 16% were afforded treatment. The majority of worldwide illicit drug–related deaths (190,000) were attrib uted to opioids. In 2016, the United States accounted for more than 25% of these deaths. 4 U.S. ED drug-related visits doubled from 2005 to 2014,5 fueled by increased supply and misuse of prescription opioids; social and economic determinants; and the low cost and easy availability of heroin, synthetic fentanyl, and analogs. 6 Between July 2016 and September 2017, U.S. opioid overdose ED visits among those aged 11 years old and older increased 29.7% overall, with significant increases across all demographics examined.

ioids; social and economic determinants; and the low cost and easy availability of heroin, synthetic fentanyl, and analogs. 6 Between July 2016 and September 2017, U.S. opioid overdose ED visits among those aged 11 years old and older increased 29.7% overall, with significant increases across all demographics examined. 7 It is noteworthy that “available data suggest that non medical prescription-opioid use is neither necessary nor sufficient for TABLE 292-1 Nonstigmatizing Substance Use Disorder Language Avoid These Terms Use These Instead Addict, user, drug abuser, junkie Person with opioid use disorder or person with opioid addiction, patient Addicted baby Baby born with neonatal abstinence syndrome Opioid abuse or opioid dependence Opioid use disorder Problem Disease Habit Drug addiction Clean or dirty urine test Negative or positive urine drug test Opioid substitution or replacement therapy Opioid agonist treatment Relapse Return to use Treatment failure Treatment attempt Being clean Being in remission or recovery Source: Data adapted from www.thenationalcouncil.org/consulting-best-practices/national-council-shareables. Accessed June 27, 2018. Tintinalli_Sec24_p1933-1966.indd 1959 8/2/19 5:19 PM

t therapy Opioid agonist treatment Relapse Return to use Treatment failure Treatment attempt Being clean Being in remission or recovery Source: Data adapted from www.thenationalcouncil.org/consulting-best-practices/national-council-shareables. Accessed June 27, 2018. Tintinalli_Sec24_p1933-1966.indd 1959 8/2/19 5:19 PM 1960 SECTION 24: Psychosocial Disorders so early intervention is needed to mitigate life-altering consequences. 19 Gaps between women and men are narrowing for prevalence, frequency, and intensity of drinking; early-onset drinking; and driving under the influence. 16,20 Women who drink are more likely to experience medical complications of alcohol use including liver injury and cirrhosis, some cancers, cognitive dysfunction, and cardiovascular complications such as stroke, hypertension, and cardiomyopathy. 21-24 National survey data demonstrate an upward trend in drinking among U.S. adults aged 60 and older, particularly among women who were found to have increased rates of binge drinking. 25 The ED is an important site for alcohol screening (Figure 292-1). SUBSTANCE USE DISORDERS The  Diagnostic and Statistical Manual of Mental Disorders, fifth edition, groups substance abuse and dependence into categories from mild to severe SUD.26 The diagnosis of SUD requires two or more of the following 11 criteria: (1) tolerance; (2) withdrawal; (3) recurrent use in greater quantities or for a greater duration than intended; (4) failed attempts to cut back or quit substance use; (5) spending a great deal of time obtain ing, using, or recovering from the substance; (6) persistent or recurrent use despite physical and or psychological consequences; (7) giving up important activities in order to use; (8) failure to fulfill responsibilities in work, school, and/or home because of recurrent use; (9) recurrent use resulting in physically hazardous behavior, such as driving under the influence; (10) persistent use despite social or interpersonal problems; and (11) craving alcohol or other drugs. Severity is based on the number of criteria met: two or three of the criteria constitute mild SUD, four to five constitute moderate SUD, and six or more constitute severe SUD. More than 20 million Americans aged 12 and older 27 and 110 million people worldwide28 meet criteria for an SUD. SCREENING, BRIEF INTERVENTION, AND REFERRAL TO TREATMENT Screening, brief intervention, and referral to treatment techniques were established in 2003 by the U.S. Substance Abuse and Mental Health Services Administration to address the gap in preventive services for unhealthy alcohol and drug use, to stem the progression to addiction by early intervention, and to address the treatment gap by promoting help seeking and facilitating access to addiction treatment and recovery support services. Screening, brief intervention, and referral to treatment have been associated with short-term benefits and reduction in cost and ED utilization. 29-43  SCREENING FOR UNHEALTHY DRINKING AND DRUG USE Brief standardized screening questions have a higher sensitivity for identifying heavy and dependent drinkers and illicit drug–using patients than noting the smell of alcohol on breath, patient self-report, or profiling based on demographics or presenting complaint. Brief screening instruments are easy to administer and may help match an individual to the most appropriate treatment resource.

ifying heavy and dependent drinkers and illicit drug–using patients than noting the smell of alcohol on breath, patient self-report, or profiling based on demographics or presenting complaint. Brief screening instruments are easy to administer and may help match an individual to the most appropriate treatment resource. Validated brief screen ing questions useful for ED providers include the National Institute on Alcohol Abuse and Alcoholism Quantity/Frequency Questions and the Single Screening Questions for Alcohol 44 and Drug Use (Table 292-2).45 Questions can be integrated into the triage electronic medical record.46 Screening for heavy smoking is also important since there is an association between heavy smoking and multiple drug use.15 An alternative approach is to implement the National Institute on Drug Abuse– Modified Alcohol, Smoking and Substance Involvement Screening Test instrument into ED practice if additional ED support personnel are available (e.g., health promotion advocate, alcohol and drug counselors, recovery coaches, trained medical workers, behavioral health or social workers). 33,47-49 The National Institute on Drug Abuse–Modified Alcohol, Smoking and Substance Involvement Screening Test instrument was developed to guide clinicians through a series of questions to identify risky substance use in their adult patients. Final scores of 4 to 26 on the instrument stratify risk and encourage clinicians to advise, assess, and assist patients with follow-up to primary care; a score of greater than 26 indicates the need for referrals to SUD specialty treatment. As part of the social history, emergency care providers can integrate questions that reflect their concern for the patient’s overall health and safety. SUD screening questions could be embedded among other preventive health issues to reduce stigma and patient resistance and encourage veracity and trust. Questions asked in a nonjudgmental, matter-of-fact fashion are well accepted by patients. Patients who are above the “low-risk” drinking guidelines could benefit from a brief intervention and primary care referral to motivate reducing consumption. For moderate to severe alcohol use, provide referral to a specialized treatment center.  THE BRIEF NEGOTIATED INTERVIEW FOR SUBSTANCE USE INTERVENTION The brief negotiated interview29,30,36,37,51,52 has four key elements: establish rapport, provide feedback, enhance motivation, and negotiate a plan of action. The first principle of promoting health behavior change is that the argument for change needs to come from the patient, not the healthcare provider. Begin a respectful, nonjudgmental conversation by recognizing the patient as the decision maker and asking the patient’s permission to talk about alcohol or drug use and health concerns. An important opportunity for early intervention may occur during an ED visit for acute medical care or a social or criminal justice crisis. 53 The entire interaction often can be accomplished in 5 to 7 minutes,51 and the conversation can take place at any point in care, such as at discharge or while suturing or casting or performing an incision and drainage of an abscess. The brief negotiated interview algorithm incorporates key elements of motivational interviewing: open-ended questions, affirmations, reflective listening, and summaries (Figure 292-2). ( See Videos: Brief Negotiated Interview and Active Referral to Treatment.) Alcohol Screening in the ED (Revised and approved by the American College of Emergency Physicians [ACEP] Board of Directors April 2011. Reaffirmed January 2017.) “ACEP believes alcohol abuse is a significant public health problem.

igure 292-2). ( See Videos: Brief Negotiated Interview and Active Referral to Treatment.) Alcohol Screening in the ED (Revised and approved by the American College of Emergency Physicians [ACEP] Board of Directors April 2011. Reaffirmed January 2017.) “ACEP believes alcohol abuse is a significant public health problem. Further, ACEP believes emergency medical professionals are positioned and qualified to mitigate the consequences of alcohol abuse through screening programs, brief intervention, and referral to treatment. ACEP encourages wide availability of resources necessary to address the needs of patients with alcohol-related problems and those at risk for them.” FIGURE 292-1. American College of Emergency Physicians policy on alcohol screening in the ED. TABLE 292-2 Single Screening Questions “Would it be okay with you if I ask you some very personal questions that I ask all my patients to improve the care I give? You do not have to answer them if you are uncomfortable.” •   Single Screening Question for Alcohol: “Do you drink beer, wine, liquor, or distilled spirits? How many times in the past year have you had 5 or more (for men)/4 or more (for women) drinks in a day?”6,44 Clarify that a standard drink is 1.5 oz of spirits, 6 oz of wine, and 12 oz of beer.6 •   Single Screening Question for Drug Use: “How many times in the past year have you used an illegal drug or used a prescription medication for nonmedical reasons?” You can add something like “. . . for instance, for the experience or feeling it gives you?”45 Tintinalli_Sec24_p1933-1966.indd 1960 8/2/19 5:19 PM

beer.6 •   Single Screening Question for Drug Use: “How many times in the past year have you used an illegal drug or used a prescription medication for nonmedical reasons?” You can add something like “. . . for instance, for the experience or feeling it gives you?”45 Tintinalli_Sec24_p1933-1966.indd 1960 8/2/19 5:19 PM CHAPTER 292:  Substance Use Disor ders      1961 Establish Rapport Establish rapport and ask the patient’s permission to discuss his or her use of alcohol and drugs. Establish an atmosphere of trust through respect. The patient is not the problem (a stigmatizing approach) but is a person who has a problem. Instead of “What’s wrong with our patient?” , an alternative approach based on compassionate curiosity would lead the clinician to inquire, “What’s happening with our patient?” Provide Feedback Elicit the patient’s thoughts on low-risk or safe alcohol and drug use. Provide information by reviewing current drink ing and drug use and guidelines. Express concern that by drinking in excess of safe limits, the patient is at risk for injury or illness. Elicit/ solicit the reaction to the guidelines. Ask patients to make a connection between alcohol and/or drug use and quality of life; possible negative consequences related to health, family, legal system, and employment; and, if applicable, the current ED visit or injury. If appropriate, discuss physical dependence, withdrawal, and the cycle of behaviors to obtain more alcohol and/or drugs. Enhance Motivation Assess readiness to change on a readiness ruler. Ask patients to mark on a drawing of a ruler, with a scale of 1 to 10, how ready they are to change, cut back, or quit their alcohol and/or drug use. If they say 5, give affirmation and say that “Y ou are 50% on the way, ” and ask, “Tell me why you didn’t mark a 2 or 3 or a lesser number?” Here is when we try to elicit change talk or reasons and motivation for change. Repeat what the patient has shared with you and follow up with, “It sounds like you have some important reasons to change, so what small steps can you take to stay healthy and safe?” If the patient shows resistance to the readiness ruler or the score is <2, then explore the pros and cons of cur rent use. A discussion of the pros and cons promotes self-questioning and draws attention to the patient’s own reasons for tipping the scale toward change. Use open-ended questions such as, “Help me to understand (or see it through your eyes) what you like and dislike about your use of alcohol?” Explore the importance to the patient of the issues that emerge. Use reflective listening to summarize what you think the patient said to verify your interpretation, for example: “On the one hand, you like the taste and how it helps you to loosen up and forget your problems, and it BNI Steps 1. Raise subject 2. Provide feedback • Review screen • Make connection • Show NIAAA guidelines and norms 3. Enhance motivation • Readiness to change • Develop discrepancy • Explore pros and cons • Use re flective listening 4. Negotiate and advise • Negotiate goal • Give advice • Summar ize • Provide handouts and suggest PC f/u • Thank patient Dialogue/Procedures Hello, I am _______. Would you mind taking a few minutes to talk with me about your alcohol use? <<PAUSE and LISTEN>>

crepancy • Explore pros and cons • Use re flective listening 4. Negotiate and advise • Negotiate goal • Give advice • Summar ize • Provide handouts and suggest PC f/u • Thank patient Dialogue/Procedures Hello, I am _______. Would you mind taking a few minutes to talk with me about your alcohol use? <<PAUSE and LISTEN>> From what I understand you are drinking [insert screening data]… We know that drinking above certain levels can cause problems, such as [insert facts]…I am concerned about your drinking. What connection (if any) do you see between your drinking and this ED visit? If pt sees connection: reiterate what pt has said If pt does not see connection: make one using facts These are what we consider the upper limits of low risk drinking for your age and sex. By low risk we mean that you would be less likely to experience illness or injury if you stayed within these guidelines. [Show readiness ruler] On a scale from 1–10, how ready are you to change any aspect of your drinking? If patient says: ≥2 ask Why did you choose that number and not a lower one? <2 or resistance ask pros and cons Help me to understand what you enjoy about drinking? <<PAUSE AND LISTEN>> Now tell me what you enjoy less about drinking. <<PAUSE AND LISTEN>> On the one hand you said, <<RESTATE PROS>> On the other hand you said, <<RESTATE CONS>> So tell me, where does this leave you? What’s the next step? What do you think you can do to stay within the safe drinking guidelines? If you can stay within these limits you will be less likely to experience [further] illness or injury related to alcohol use. This is what I’ve heard you say…Here is a drinking agreement I would like you to fill out, reinforcing your new drinking goals. This is really an agreement between you and yourself. Provide drinking agreement [pt keeps 1 copy] Suggest Primary Care f/u to discuss drinking level/pattern Thank patient for his/her time FIGURE 292-2. Screening, brief intervention, and referral to treatment algorithm as taught in the standardized ED curriculum. BNI = brief negotiated interview; f/u = follow-up; NIAAA = National  Institute  on  Alcohol  Abuse  and  Alcoholism;  PC  =  primary  care;  pt  =  patient.  [Reproduced  with  permission  from  D’Onofrio  G,  Pantalon  MV,  Degutis  LC,  Fiellin  DA,  O’connor  PG: Development and implementation of an emergency  practitioner-performed brief intervention for hazardous  and harmful drinkers in the emergency department. Acad Emerg Med 12: 249, 2005. Copyright John Wiley & Sons.] Tintinalli_Sec24_p1933-1966.indd 1961 8/2/19 5:19 PM

alon  MV,  Degutis  LC,  Fiellin  DA,  O’connor  PG: Development and implementation of an emergency  practitioner-performed brief intervention for hazardous  and harmful drinkers in the emergency department. Acad Emerg Med 12: 249, 2005. Copyright John Wiley & Sons.] Tintinalli_Sec24_p1933-1966.indd 1961 8/2/19 5:19 PM 1962 SECTION 24: Psychosocial Disorders is something to do when you’re bored. On the other hand, you said you don’t like how you feel the next day and that wrecking your car in a crash and ending up in the ED is no fun. Y ou also told me you are spending a lot of money on drinking and are concerned about not meeting some responsibilities. So then, in the balance, where does that leave you?” Negotiate and Advise Negotiate an action plan. Explore with patients what life might be like if they made these changes. What would be the benefits of change, and what would be the challenges? Add the steps they would need to take to address challenges and explore and support confidence in ability to make a change. Offer a menu of options and resources to assist with the change plan, including, if appropriate, referrals to primary care providers and SUD treatment. Document the plan. Ask the patient to state in her or his own words the agreed-on steps and document them on a piece of paper or discharge instructions as a reminder of goals (a prescription for change). Reflect back to the patient and reinforce reasons for, and steps toward, change. End the conversation by thanking the patient for being honest and spending time talking with you. Afterward, take a minute for self-assessment using the FLOAT mne monic: To what degree did you provide feedback? Did you listen carefully? Did you ask open-ended questions? Did you offer affirmations and alternatives? Did the patient have enough time to talk, or did you do the majority of talking? Did you negotiate a concrete action plan?  REFERRAL TO TREATMENT Factors that often accompany unhealthy alcohol and drug use, such as psychiatric illness, trauma, homelessness, low level of health literacy, lack of insurance coverage or ability to pay for medications, criminal justice involvement, absence of family support, and limited availability of treatment and recovery support services, make patient management and disposition challenging. Effective linkage to SUD treatment can be facilitated by training ED staff in screening, brief intervention, and referral to treatment. Develop an ED collaborative team with staff such as behavioral health and social workers, care managers, psychologists, nurse specialists, peer alcohol and drug counselors, volunteers from Alcoholics Anonymous or Narcotics Anonymous, health promotion advocates, or recovery coaches to enhance the efforts of existing staff and motivate and assist patients with identifying and accessing treatment options. 33,47-49,52 Build and maintain a referral and resource service network.33,47,52 Current practice in most EDs is to provide patients and family members with a list of detoxification or treatment resources in the community. The Center for Substance Abuse Treatment at the U.S. Department of Health and Human Services has an online resource locator (http:// dasis3.samhsa.gov).

service network.33,47,52 Current practice in most EDs is to provide patients and family members with a list of detoxification or treatment resources in the community. The Center for Substance Abuse Treatment at the U.S. Department of Health and Human Services has an online resource locator (http:// dasis3.samhsa.gov). The resource list and referral networks ideally would include a continuum of specialized treatment facilities for patients with co-occurring medical, traumatic, and psychiatric illnesses; inpatient and outpatient detoxification, acupuncture, and medication for addiction treatment such as methadone maintenance programs, buprenorphine, and oral and IM naltrexone for opioid and alcohol addiction; outpa tient individual and group counseling; intensive outpatient or partial hospitalization; sober housing and residential treatment communities; Alcoholics Anonymous and Narcotics Anonymous meetings; and programs focused on the needs of women, culture-specific programs, and programs designed for gay, lesbian, and transgender clients. If patients are not ready to enter specialized treatment or attend Alcoholics Anonymous or Narcotics Anonymous, then try to provide information and negotiate a safety plan such as the identification of a designated driver or use of a taxicab when drinking heavily or avoiding drinking while taking medications. The injection drug user who is not ready to accept a treatment referral may accept testing for human immunodeficiency virus or hepatitis C virus, condoms, a referral to a syringe exchange program, or other harm reduction strategies. The patient with opioid use disorder, heroin or fentanyl use, or a recent opioid overdose would benefit from overdose education, provision of naloxone through direct distribution or prescription, and a safe discharge plan that includes engaging the patient’s social support network and linkage to addiction treatment. Opioid agonist therapy, also known as medicationassisted treatment, with buprenorphine or methadone is vital to reduce mortality among patients with opioid use disorder.  THE MEDICAL EVALUATION EDs often function as sources for the medical evaluation before patient transfer to a substance or psychiatric treatment facility. There is considerable variability in the levels of medical care provided in such facilities, ranging from facilities that manage an array of chronic health problems to those with minimal nursing support only for very stable patients. Medical evaluation means that the patient does not have a medical emergency or acute medical condition requiring hospitalization or preventing addiction treatment. Patients with mild or moderate uncomplicated alcohol withdrawal that responds well to initial ED treatment (i.e., those with no trauma or major medical comorbidities, with no suicidal or homicidal ideation or a seizure disorder) can be managed successfully in a detoxification unit. The criteria for placement in a detoxification unit are very similar to those for safe discharge and include the following: patients are stable (in the short term rather than long term) and ambulatory, can take oral medications, and are not suicidal or likely to seize. Patients on medica tions (including buprenorphine) should bring them to the treatment facility or be given prescriptions or provided with several doses. Stable patients with dual diagnoses who are not suicidal or acutely psychotic can be medically cleared for transfer, as long as they have a supply of current psychiatric and nonpsychiatric medications and can be expected to take their medications correctly and reliably.

ven prescriptions or provided with several doses. Stable patients with dual diagnoses who are not suicidal or acutely psychotic can be medically cleared for transfer, as long as they have a supply of current psychiatric and nonpsychiatric medications and can be expected to take their medications correctly and reliably. Because detoxification from opioids can place patients at high risk for opioid overdose once discharged because of loss of tolerance, opioid overdose education and provision of take-home naloxone are critically important. PHARMACOLOGIC MANAGEMENT FOR ALCOHOL, OPIOID, AND SEDATIVE USE DISORDERS A large body of evidence supports the efficacy of pharmacologic inter ventions for the treatment of alcohol, opioid, and sedative use disorders. Management of alcohol, opioid, and sedative intoxication; overdose; and withdrawal syndromes is covered in chapters dedicated to each substance. Pharmacologic management of individuals with moderate to severe alcohol, opioid, and sedative use disorders is discussed here. Many of these treatments will not be typically initiated in the ED, but knowledge of their existence and effectiveness is important for the ED provider to understand both when caring for patients who are pre scribed these medications and in providing referrals for medical man agement to patients with SUDs.  ALCOHOL USE DISORDER MANAGEMENT Medications for the treatment of alcohol use disorder include alco hol antagonist agents, such as disulfiram (Antabuse®), and medica tions that directly reduce alcohol consumption, including acamprosate (Campral®), oral naltrexone, and long-acting injectable naltrexone (Vivitrol®). Disulfiram is an oral medication that irreversibly binds to and inhibits alcohol dehydrogenase, causing the unpleasant disulfiramethanol reaction, which can include nausea, vomiting, diaphoresis, flushing, and tachycardia, the avoidance of which serves as a deterrent for the consumption of alcohol. 54,55 Acamprosate, an amino acid derivative that increases γ-aminobutyric acid transmission, was previously found to be effective in reducing return to alcohol use in a number of U.S. and European studies, but did not show efficacy in a large multicenter trial. In the Combined Pharmacotherapies and Behavioral Interventions study, a large prospective multisite study investigating the effect of combinations of medications and behavioral therapies on alcohol use disorder, acamprosate showed no significant effect on drinking versus placebo, either by itself or with any combination of naltrexone, cognitive behavior therapy, or both. Naltrexone, an opioid receptor antagonist with no intrinsic agonist activity, is hypothesized to lead to reduce alcohol consumption by indi rectly affecting the dopaminergic reward pathway through effects on the µ opioid receptor. 55 Early studies reported that oral naltrexone, in conjunction with behavioral intervention, led to lower reports of crav ing, fewer drinks and drinking days, and fewer relapses; more recent systematic reviews report that naltrexone is effective at reducing return Tintinalli_Sec24_p1933-1966.indd 1962 8/2/19 5:19 PM

r. 55 Early studies reported that oral naltrexone, in conjunction with behavioral intervention, led to lower reports of crav ing, fewer drinks and drinking days, and fewer relapses; more recent systematic reviews report that naltrexone is effective at reducing return Tintinalli_Sec24_p1933-1966.indd 1962 8/2/19 5:19 PM CHAPTER 292:  Substance Use Disor ders      1963 to heavy drinking and the amount of alcohol consumed. 56,58 A longacting IM naltrexone injection was approved by the U.S. Food and Drug Administration in 2006 and can decrease heavy drinking days while avoiding the challenges of taking a daily medication. 59 Importantly, these medications are not mutually exclusive to each other, as multiple stud ies have shown improved outcomes in patients taking a combination of medications for alcohol use disorder, as well as medications augmented with behavioral or psychosocial interventions. 56,57  OPIOID USE DISORDER MANAGEMENT A substantial body of literature supports medications for addiction treatment or medication-assisted treatment for moderate or severe opioid use disorders, and such treatment is recognized by the Centers for Disease Control and Prevention, National Institute of Drug Abuse, and World Health Organization. 60-63 Collectively, methadone and buprenorphine are referred to as opioid agonist treatments and have been associated with a variety of improved outcomes including reduced craving, decreased opioid use, decreased crime, decreased nonfatal overdose, decreased mortality, cost-effectiveness, and improved social functioning. 61,62,64-66 Methadone Methadone is a long-acting oral medication with full opioid agonist properties at the µ receptor. Methadone can be prescribed by physicians for the treatment of pain, but the prescription of methadone for treatment of addiction is limited by the Federal Narcotics Act to inpatient units or outpatient facilities licensed by the U.S. Drug Enforcement Administration. Several large-scale studies have shown a relationship between outcomes and methadone dose, with improved outcomes including less opioid and cocaine use at doses above 60 milligrams. 61,67 Methadone has been associated with QT prolongation on the ECG.68 Buprenorphine Buprenorphine is a partial opioid agonist and a weak antagonist. It has a high affinity for µ receptors, displacing other opioids from the receptor and causing acute withdrawal in patients who have recently used opioids. The antagonist effects of buprenorphine block respiratory depression and provide a good margin of safety to treat withdrawal or to provide opioid substitution therapy. The U.S. Food and Drug Administration approved two sublingual formulations of buprenorphine in 2002 for the treatment of opioid dependence. The preferred preparation is a combination of buprenorphine combined with naloxone in a ratio of 4:1, as a sublingual tablet or film (brand name Suboxone® or Zubsolv®) to prevent diversion and overdoses. 56,69 The naloxone component is rapidly bioavailable if the medication is tam pered with and will precipitate withdrawal symptoms in opioid users. Non–naloxone-containing films are traditionally reserved for pregnant patients or settings with directly observed medication ingestion. Over doses can be managed with naloxone. Advise patients about the risks of concurrent benzodiazepine use, including respiratory depression and overdose of prescribed and illicit sedatives with all opioids, including methadone and buprenorphine. The Drug Addiction Treatment Act of 2000 established office-based opioid treatment in an effort to integrate treatment options into comprehensive clinical care practice and reduce stigmatization of medicationassisted treatment.

of prescribed and illicit sedatives with all opioids, including methadone and buprenorphine. The Drug Addiction Treatment Act of 2000 established office-based opioid treatment in an effort to integrate treatment options into comprehensive clinical care practice and reduce stigmatization of medicationassisted treatment. The prescription of methadone for treatment of addiction is limited by the Federal Narcotics Act to inpatient units or outpatient facilities licensed by the U.S. Drug Enforcement Administration, and buprenorphine is limited to certified clinicians in office- or clinicbased practices. However, there is a “3-day rule” (Title 21, Code of Federal Regulations, Part 1306.07b) that allows a practitioner who is not separately registered as a narcotic treatment program or certi fied as a “waivered Drug Addiction Treatment Act of 2000” physician to administer (but not prescribe) narcotic drugs to a patient to relieve acute withdrawal symptoms while arranging for referral to treatment (http://www.buprenorphine.samhsa.gov/faq.html). Only 1 day’s supply may be administered or given to a patient, and this may be done for 72 hours only, which cannot be extended. The intent of Title 21, Code of Federal Regulations, Part 1306.07b is to provide flexibility in emergency situations and is especially relevant to emergency physicians. This offers patients options for relief of withdrawal symptoms to bridge the patient for follow-up to either a specialized treatment program or an officebased physician program in the community. A study of 329 ED patients found that patients with moderate or severe opioid use disorder randomized to receive a brief intervention with initiation of buprenorphine in the ED with primary care follow-up were significantly more likely to be engaged in formal treatment for opioid use disorder at 30 days (78%; 95% confidence interval [CI], 70% to 85%), compared with referral alone (37%; 95% CI, 28% to 47%) and brief intervention with a facilitated, direct referral (45%; 95% CI, 36% to 54%; P < .001). The buprenorphine group reduced the number of days of illicit opioid use per week from 5.4 days (95% CI, 5.1 to 5.7) to 0.9 days (95% CI, 0.5 to 1.3) versus a reduction from 5.4 days (95% CI, 5.1 to 5.7) to 2.3 days (95% CI, 1.7 to 3.0) in the referral group and from 5.6 days (95% CI, 5.3 to 5.9) to 2.4 days (95% CI, 1.8 to 3.0) in the brief intervention group (P < .001 for both time and intervention effects; P = .02 for the interaction effect). This important study from 2015, combined with the rapid increase in opioid-associated fatalities, laid the foundation for EDs to help bridge the treatment gap for patients with opioid use disorder by collaborating with local treatment providers to develop pathways for rapid linkage to care. The starting dose for treatment of opioid withdrawal is sublingual buprenorphine/naloxone, 4 to 8 milligrams of buprenorphine/2 milligrams of naloxone, given to patients who meet criteria for moderate or severe opioid use disorder and show signs of opioid withdrawal according to the Clinical Opiate Withdrawal Scale (Figure 292-3). 56,71 If the patient does not yet exhibit symptoms of at least a score of 7 on the Clinical Opiate Withdrawal Scale, a physician with a Drug Addiction Treatment Act of 2000 waiver can prescribe a short course of buprenorphine and discharge with instructions and with close follow-up in place (Figure 292-4). In the case of naloxone administration after an over dose, patients will likely not meet criteria for opioid withdrawal during the length of an ED stay after the naloxone wears off. Thus, if they wish to start buprenorphine, they will be discharged with a prescription for unobserved induction with close follow-up.

-4). In the case of naloxone administration after an over dose, patients will likely not meet criteria for opioid withdrawal during the length of an ED stay after the naloxone wears off. Thus, if they wish to start buprenorphine, they will be discharged with a prescription for unobserved induction with close follow-up. Naltrexone Naltrexone is a long-acting µ receptor antagonist that reduces relapse or return to opioid use in patients by blockading any positive reinforcement from taking opioids. 71 Naltrexone is best suited to patients with opioid use disorder who are highly motivated to avoid opioids, as it provides modest relief from craving, or who were recently released from a controlled environment such as incarceration or an abstinence program. Naltrexone requires at least a 7-day period with out opioid exposure to avoid the complication of precipitated with drawal. Recent studies comparing it with opioid agonist treatment such as buprenorphine highlight the fact that patients may refuse treatment, and evaluation of effectiveness has been complicated by poor study and treatment retention. 55,56 Benzodiazepines The chronic use of sedatives, particularly benzo diazepines, is a common comorbidity with other substance use dis orders. The emergency provider often encounters patients with signs and symptoms of withdrawal, when prescriptions are not filled after hospitalizations or surgeries. Symptoms of withdrawal may develop up to 7 to 10 days after stopping chronic benzodiazepine use, and patients may develop withdrawal seizures. The clinical picture resembles alcohol withdrawal with symptoms of hypertension, tachycardia and tachypnea, tremulousness, anxiety, agoraphobia, insomnia, altered mental status, delirium, and hallucinations. Medical management for the treatment of benzodiazepine withdrawal is complicated by risk of withdrawal sei zures. Most evidence supports a prolonged benzodiazepine taper over 4 to 12 weeks. 57 A 2006 Cochrane review found support for a gradual benzodiazepines taper, although it did not find significant differences between patients being tapered on long- versus short-acting benzodiazepines, and no additional benefit was found to support the adjunct use of additional medications such as propranolol or hydroxyzine. 58 A metaanalysis of 29 studies evaluating strategies for the discontinuation of benzodiazepines found that both minimal interventions and systematic discontinuation of benzodiazepines were more effective than treatment as usual and concluded that there is adequate support of the stepped care model, in which minimal intervention is followed by systematic discontinuation. 57 Preliminary evidence for the use of carbamazepine exists, but large, controlled trials have not been reported. 59 Benzodiazepines should be continued in collaboration with the primary care provider or mental health provider, and the patient should be referred to an Tintinalli_Sec24_p1933-1966.indd 1963 8/2/19 5:19 PM

7 Preliminary evidence for the use of carbamazepine exists, but large, controlled trials have not been reported. 59 Benzodiazepines should be continued in collaboration with the primary care provider or mental health provider, and the patient should be referred to an Tintinalli_Sec24_p1933-1966.indd 1963 8/2/19 5:19 PM 1964 SECTION 24: Psychosocial Disorders addiction medicine specialist as needed. If benzodiazepines are neces sary for continued treatment of debilitating psychiatric illness, patients should have a psychiatry consult or evaluation as these medications are frequently inappropriately prescribed or overprescribed. REDUCTION OF HARM FROM OPIOID USE DISORDER Many ED patients with opioid use disorder will not be ready to enter treatment at the time of the ED visit, but we still have an opportunity to help them progress in their readiness to seek treatment, prevent individual and societal harms associated with drug use, and prevent future overdose deaths. Syringe access 72,73 and supervised consumption facilities have demonstrated lower human immunodeficiency virus and hepatitis C virus transmission rates, fewer injection drug risk behav iors, decreased overdose incidents, and more rapid entry into detox programs. 74-76 Naloxone, a competitive opioid receptor antagonist, has been distributed for bystander opioid overdose reversal since 1996 at community naloxone distribution programs. 77 Community naloxone distribution programs have demonstrated that lay people and injection drug users can reliably administer naloxone. 78-82 Population studies have noted that naloxone distribution is associated with decreased commu nity overdose deaths83 and decreased deaths among people released from prison,84 is cost-effective when provided to heroin users, 85 and reduces opioid-related ED visits when co-prescribed with opioids for chronic pain by a primary care provider. 86 Given the increasing incidence of opioid overdose, some cities and states have started storing publicly accessible naloxone with automated external defibrillator devices, in designated NaloxBoxes, and at public schools. Patient’s Name:_____________________ Reason for this assessment:___________________________________________________________________ Resting Pulse Rate: ________beats/minute Measured after patient is sitting or lying for one minute Date and Time ____/____/____:_________ 0 pulse rate 80 or below 1 pulse rate 81-100 2 pulse rate 101-120 4 pulse rate greater than 120 Sweating: Over past 1/2 hour not accounted for by room temperature or patient activity.

esting Pulse Rate: ________beats/minute Measured after patient is sitting or lying for one minute Date and Time ____/____/____:_________ 0 pulse rate 80 or below 1 pulse rate 81-100 2 pulse rate 101-120 4 pulse rate greater than 120 Sweating: Over past 1/2 hour not accounted for by room temperature or patient activity. 0 no report of chills or flushing 1 subjective report of chills or flushing 2 flushed or observable moistness on face 3 beads of sweat on brow or face 4 sweat streaming off face Restlessness Observation during assessment 0 able to sit still 1 reports difficulty sitting still, but is able to do so 3 frequent shifting or extraneous movements of legs/arms 5 unable to sit still for more than a few seconds Bone or Joint aches If patient was having pain previously, only the additional component attributed to opiates withdrawal is scored 0 not present 1 mild diffuse discomfort 2 patient reports severe diffuse aching of joints/muscles 4 patient is rubbing joints or muscles and is unable to sit still because of discomfort Runny nose or tearing Not accounted for by cold symptoms or allergies 0 not present 1 nasal stuffiness or unusually moist eyes 2 nose running or tearing 4 nose constantly running or tears streaming down cheeks Pupil size 0 pupils pinned or normal size for room light 1 pupils possibly larger than normal for room light 2 pupils moderately dilated 5 pupils so dilated that only the rim of the iris is visible GI Upset: Over last 1/2 hour 0 no GI symptoms 1 stomach cramps 2 nausea or loose stool 3 vomiting or diarrhea 5 multiple episodes of diarrhea or vomiting Tremor Observation of outstreched hands 0 no tremor 1 tremor can be felt, but not observed 2 slight tremor observable 4 gross tremor or muscle twitching Yawning Observation during assessment 0 no yawning 1 yawning once or twice during assessment 2 yawning three or more times during assessment 4 yawning several times/minute Anxiety or Irritability 0 none 1 patient reports increasing irritability or anxiousness 2 patient obviously irritable or anxious 4 patient so irritable or anxious that participation in the assessment is difficult Gooseflesh skin 0 skin is smooth 3 piloerrection of skin can be felt or hairs standing up on arms 5 prominent piloerrection Total Score ________ The total score is the sum of all 11 items Initials of person completing assessment: ______________ For each item, circle the number that best describes the patient’s signs or symptom. Rate on just the apparent relationship to opiate withdrawal. For example, if heart rate is increased because the patient was jogging just prior to assessment, the increase pulse rate would not add to the score. APPENDIX 1 Clinical Opiate Withdrawal Scale (COWS) by [HSRL - Health Science Research Library] at 14:04 02 September 5-12 = mild; 13-24 = moderate; 25-36 = moderately severe; more than 36 = severe withdrawal This version may be copied and used clinically. Journal of Psychoactive Drugs Volume 35 (2), April - June 2003 FIGURE 292-3. Clinical Opiate Withdrawal Scale. [Reproduced with permission from Wesson DR, Ling W: The Clinical Opiate Withdrawal Scale (COWS). J Psychoactive Drugs 35: 253, 2003. Copyright Taylor & Francis Ltd.] Tintinalli_Sec24_p1933-1966.indd 1964 8/2/19 5:19 PM

f Psychoactive Drugs Volume 35 (2), April - June 2003 FIGURE 292-3. Clinical Opiate Withdrawal Scale. [Reproduced with permission from Wesson DR, Ling W: The Clinical Opiate Withdrawal Scale (COWS). J Psychoactive Drugs 35: 253, 2003. Copyright Taylor & Francis Ltd.] Tintinalli_Sec24_p1933-1966.indd 1964 8/2/19 5:19 PM CHAPTER 292:  Substance Use Disor ders      1965 In addition to referring patients to addiction treatment, community syringe access, and naloxone distribution programs, in 2009 EDs started providing take-home naloxone to patients at high risk of opioid over dose to prevent opioid overdose death. 88-91 Naloxone can be either prescribed for pickup at a pharmacy or given to patients in a preassembled “kit” that includes administration instructions, a mouth barrier for CPR, and two doses of naloxone. Provision of naloxone at the time of the ED visit decreases access barriers and ensures that the patient and/or their family member has received the medication. Naloxone can be given IM or intranasally. IM naloxone can be prescribed as two single-dose vials, 0.4 milligram/mL with a 3-mL syringe and 1-inch 23-guage needle ( Table 292-3). This is the cheapest formulation, but it requires drawing up the medication into a syringe prior to administration. Another IM formulation, Evzio  , is a U.S. Food and Drug Administration–approved prefilled autoinjector. It has a single dose of naloxone 2 milligrams/0.4 mL (prior formulation had 0.4-milligram dose) and comes in packs of two. It is easy to use but more expensive and requires prior insurance authorization, limiting its utility in the ED setting. Narcan® is a U.S. Food and Drug Administration–approved intranasal form of naloxone that contains 4 milligrams of naloxone and requires no assembly. It is very easy to use but more expensive than generic formulations. Generic intranasal naloxone is prescribed as two prefilled Luer-Lock needless syringes containing 2 milligrams/2 mL to be dispensed with a mucosal atomizing device. This formulation requires assembly before use. Diagnosis of Moderate to Severe Opioid Use Disorder Assess for opioid type and last use Patients taking methadone may have withdrawal reactions to buprenorphine up to 72 hours after last use Consider consultation before starting buprenorphine in these patients Dosing: 4–8 milligrams SL* Dosing: None in ED Unobserved buprenorphine induction and referral for ongoing treatment Referral for ongoing treatment ED-Initiated Buprenorphine If initial dose 4 milligram SL repeat 4 milligram SL for total 8 milligram All Patients Receive: -Brief Intervention -Overdose Education -Naloxone Distribution Prescription 16-milligram dosing for each day until appointment for ongoing treatment Notes: *Clinical Opiate Withdrawal Scale (COWS) ≥ 13 (Moderate-Severe) consider starting with 8 milligram buprenorphine or buprenorphine/naloxone SL **If patient remains in moderate withdrawal may consider adding additional 4 milligram and observation for 60 minutes ***Consider high dosing in consultation with an Addiction Medicine Specialist Warm hand-offs with specific time & date to opioid treatment providers/ programs within 24–72 hours whenever possible All patients should be educated regarding dangers of benzodiazepine and alcohol co-use Ancillary medication treatments with buprenorphine induction are not needed Waivered provider able to prescribe buprenorphine? Waivered provider able to prescribe buprenorphine? Observe** COWS Consider return to the ED for 2 days of 16-milligram dosing (72-hour rule)*** Referral for ongoing treatment Observe for 45–60 min No adverse reaction YES NO YES NO (≥8) mild - severe withdrawal (0–7) none - mild withdrawal FIGURE 292-4. ED-initiated  buprenorphine. SL  =  sublingual.

ribe buprenorphine? Observe** COWS Consider return to the ED for 2 days of 16-milligram dosing (72-hour rule)*** Referral for ongoing treatment Observe for 45–60 min No adverse reaction YES NO YES NO (≥8) mild - severe withdrawal (0–7) none - mild withdrawal FIGURE 292-4. ED-initiated  buprenorphine. SL  =  sublingual. [Adapted  from  study  protocol  D’Onofrio  G,  O’Connor  PG,  Pantalon  MV,  et  al:  Emergency  department-initiated buprenorphine/naloxone treatment for opioid dependence. JAMA 313: 1636, 2015. The study was supported by grant 5RO1DA025991 from National Institute on Drug Abuse. https/www .drugabuse.gov/ed-buprenorphine] TABLE 292-3 Naloxone Formulations Characteristics and Prescriptions Generic Intramuscular Evzioø Auto-Injector Generic Intranasal Narcan® Nasal Spray Dose 0.4 milligram/mL 2 milligrams/0.4 mL 1 milligram/mL 4 milligrams/0.1 mL Titratable dose X   X Assembly required X   X Cost $ $$$ $$ $$ Prescription and quantity Two single-use 1-mL vials PLUS two 3-mL syringes with 23- to 25-gauge 1- to 1.5-inch IM needles; two refills One two-pack of two 2 milligram/0.4 mL prefilled autoinjector devices; two refills Two 2-mL Luer-Jet  Luer-Lock needleless syringes plus two mucosal atomizer devices (MAD-300); two refills One two-pack of two 4 mg/0.1 mL intranasal devices; two refills Tintinalli_Sec24_p1933-1966.indd 1965 8/2/19 5:19 PM

; two refills One two-pack of two 2 milligram/0.4 mL prefilled autoinjector devices; two refills Two 2-mL Luer-Jet  Luer-Lock needleless syringes plus two mucosal atomizer devices (MAD-300); two refills One two-pack of two 4 mg/0.1 mL intranasal devices; two refills Tintinalli_Sec24_p1933-1966.indd 1965 8/2/19 5:19 PM 1966 SECTION 24: Psychosocial Disorders TABLE 292-4 Identifying Substance Abuse Risk When assessing a prescription drug monitoring program (PDMP) profile, it is important to look at the following factors: •   From how many providers did the patient receive prescriptions? — Patients who used 4 or more prescribers or 4 or more pharmacies in 6 months may have risk of death from overdose.59,60 •   Is the patient taking both opioids and benzodiazepines? — Patients who use combinations of medications may be at increased risk for overdose.61 •   How many morphine milligram equivalents of opioids is the patient taking per day? — Patients who take 50 to 100 morphine milligram equivalents per day are at greater risk of overdose death.62-64 •   Is the patient taking long-acting/extended-release (LA/ER) opioids? — Patients taking LA/ER may be at increased risk for overdose.65 •   How often did the patient fill another prescription before the previous one was scheduled to finish? — Early refills indicate nonmedical use or noncompliance with treatment plan.65 •   Is the patient taking buprenorphine? — Patients taking buprenorphine are likely under the care of a pain specialist who should be contacted prior to prescribing a scheduled medication. •   Is the patient taking psychiatric medications, such as methylphenidate? — Psychiatric comorbidities are associated with increased risk of overdose. •   If reported by the PDMP, how often did the patient self-pay? — Patients may pay out of pocket for a prescription without involving an insurer to avoid detection of nonmedical use. Primary considerations when considering distributing naloxone include state regulatory barriers, which can limit direct to patient naloxone distribution and third-party prescribing; cost; and patient education. Naloxone is covered by most insurance plans. Any trained staff member can provide overdose prevention, response, and naloxone administration education. Patient education is best done in person in combination with facilitation of treatment referral; however, it can also be done with video. SAFE PRESCRIBING OF OPIOID PAIN RELIEVERS Emergency providers commonly treat painful conditions. 92 Opioids are frequently prescribed for patients with pain, with a multicenter study showing that 17% of discharged patients received an opioid prescription. With heightened awareness of the risks associated with opioids, that percentage is decreasing, but it is likely that opioids will always continue to have a role for certain ED patients with pain. ED prescribing is not a significant contributor to the overall number of opioid prescriptions writ ten annually in the United States, providing only about 4% to 5% of the total number of opioid prescriptions and about 2% when converted to morphine equivalents. 94,95 However, providers must be aware that shortterm ED prescriptions can have long-term consequences: One study showed that 12% of opioid-naive patients given an ED opioid prescrip tion had recurrent use, 96 and another concluded that about one third of patients with opioid use disorder who were first exposed to opioids by a legitimate prescription obtained that prescription from the ED. Standardization of treatment is key: There is currently wide variation in rates of opioid prescribing among physicians practicing within the same ED, and higher-intensity opioid prescribers within an individual department are more likely to have patients who are on opioids long term.

ined that prescription from the ED. Standardization of treatment is key: There is currently wide variation in rates of opioid prescribing among physicians practicing within the same ED, and higher-intensity opioid prescribers within an individual department are more likely to have patients who are on opioids long term. Furthermore, the longer the duration of an initial opioid prescription, the more likely it is the patient will develop long-term use, 99 leading to the following recommendation by the Centers for Disease Control and Prevention: “When opioids are used for acute pain, clinicians should prescribe the lowest effective dose of immediate-release opioids and should prescribe no greater quantity than needed for the expected duration of pain severe enough to require opioids. Three days or less will often be sufficient; more than seven days will rarely be needed. ” Therefore, a framework for safe prescribing of opioids from the ED is essential to incorporate into practice and consists of the following four pillars. 1. Determine if an opioid is indicated . There is mounting evidence that outcomes for acutely painful conditions are the same whether or not an opioid is used. For example, for patients with acute arm or leg sprain pain, the combination of ibuprofen and acetaminophen results in the same level of pain reduction at 2 hours as do combinations of acetaminophen with oxycodone, hydrocodone, or codeine. 101 Like wise, patients with nonradicular back pain who were given naproxen had similar functional outcomes at 1 week whether or not they also took oxycodone/acetaminophen or cyclobenzaprine. 102 Given these similar outcomes, it would be prudent to use nonopioid pain reliev ers (e.g., acetaminophen, ibuprofen, topical lidocaine) and avoid the exposure altogether. A formal “alternatives to opioids” program can be created, which encourages use of nonopioid pain medications, triggerpoint injections, nitrous oxide, and ultrasound-guided nerve blocks to avoid opioids when possible. 2. Screen patients for opioid misuse risk factors. If the decision is made to prescribe an opioid, determine whether the patient is at higher risk for future opioid misuse. Several screening tools have been produced for this purpose, including the Screener and Opioid Assessment for Patients with Pain–Revised and the Opioid Risk Tool. 103,104 It is important to note that these tools were derived and validated in non-ED settings, and recently, the Centers for Disease Control and Prevention declared that the tools have insufficient accuracy for classification of patients as at low or high risk for abuse or misuse. 105 It is therefore prudent to use caution for all patients when prescribing opioids, although be particularly careful when patients have high-risk features that are detected by these tools, such as concomitant psychiatric illness and/or previous personal or family history of drug or alcohol abuse. 3. Utilize a prescription drug monitoring program. Nearly all states have implemented prescription drug monitoring programs that track the prescribing and dispensing of controlled substances at the pharmacy level. 106 When first implemented, states with prescription drug monitoring programs appeared to have lower rates of substance abuse treatment admission and lower rates of increase in abuse/mis use compared to states that did not have them. 107 Prescription drug monitoring program data can change prescribing behavior because providers do not have adequate sensitivity or positive predictive value in detecting certain aberrant drug-related behaviors (e.g., “doctor shopping”) without the aid of this tool.

se/mis use compared to states that did not have them. 107 Prescription drug monitoring program data can change prescribing behavior because providers do not have adequate sensitivity or positive predictive value in detecting certain aberrant drug-related behaviors (e.g., “doctor shopping”) without the aid of this tool. 108 Although they should be used prior to every opioid prescription, there are limitations to these databases, particularly that they do not detect medications that are diverted or purchased illegally, which are the main sources of non–medically used opioid pain relievers. 109,110 Use prescription drug monitoring program data along with history, physical examination, and clinical impression. Do not use prescription drug monitoring program data as a reason to withhold adequate and necessary analgesia. Several factors from prescription drug monitoring program data may suggest concerning substance abuse risk (Table 292-4). 4. Educate about safe opioid use. Every patient who receives an opioid prescription should be provided with specific education about safe use and the risks of the medication. This education should include the following: (1) use recommended nonopioid pain relievers (e.g., acetaminophen and ibuprofen, if not contraindicated) first and understand that the opioid is an adjunct that should be used only to make the pain tolerable but not remove the pain entirely; (2) immediately stop use of the opioid medication once the pain is tolerable with nonopioid medications; (3) safely store the medication away from others in the household who may be at increased risk of nonmedical use, such as adolescents; and (4) dispose of any unused medication promptly and properly, which can now be done at most pharmacies and police stations. REFERENCES The complete reference list is available online at www.TintinalliEM.com. Tintinalli_Sec24_p1933-1966.indd 1966 8/2/19 5:19 PM