Updated Guidelines for Nonopioid Use Disorders in the ED

TOPLINE: 

The Society for Academic Emergency Medicine (SAEM) has released the fourth Guidelines for Reasonable and Appropriate Care in the Emergency Department (GRACE-4), which focus on the management of nonopioid use disorders, particularly alcohol withdrawal syndrome (AWS), alcohol use disorder (AUD), and cannabinoid hyperemesis syndrome (CHS).

METHODOLOGY:

• The SAEM GRACE-4 Writing Team framed clinically relevant questions on the management of adult patients with substance use disorders in the emergency department.
• The authors performed a systematic review of seven studies, including three retrospective cohort studies (510 patients), two retrospective chart reviews (378 patients), and two randomized controlled trials (146 patients).

TAKEAWAY: 

• For patients with moderate to severe alcohol withdrawal being admitted to the hospital, phenobarbital is recommended in addition to benzodiazepines.
• For adults with AUD who are not taking opioids, guidelines recommend naltrexone or acamprosate when naltrexone is contraindicated to prevent or reduce heavy drinking and provide a bridging prescription for up to 4 weeks until follow-up.
• For adults with AUD, gabapentin is suggested for reducing the number of heavy drinking days and improving withdrawal symptoms, but caution is advised due to its potential for misuse.
• For adults with CHS, haloperidol, droperidol, or topical capsaicin is suggested alongside usual care to manage symptoms.

IN PRACTICE:

“The balance of desirable and undesirable effects favors prescribing anticraving medications in the ED for people with AUD. This is based on indirect evidence demonstrating the effectiveness of naltrexone, acamprosate, and gabapentin in reducing heavy drinking days and increasing abstinence,” the authors wrote.

SOURCE:

The study was led by Bjug Borgundvaag, PhD, Schwartz/Reisman Emergency Medicine Institute at Sinai Health System, Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada, and published online in Academic Emergency Medicine.

LIMITATIONS:

The limitations of this study include topic selection and the lack of direct evidence. Despite reaching a consensus on the clinical importance of managing nonopioid use disorders, the SAEM GRACE Steering Committee chose the topic based on clinical relevance rather than nomenclature availability or feasibility studies. Committee size and funding were also limitations. 

DISCLOSURES:

The SAEM GRACE-4 and the broader SAEM GRACE initiative received funding from the Society for Academic Emergency Medicine. All SAEM GRACE-4 Writing Team members disclosed potential conflicts, and all but one author were able to participate as voting members with these disclosures.