Opioid Commission Recommendations and the Three-Day Rule

November 02, 2017|11:52 a.m.| ASTHO Staff

This week, the President’s Commission on Combating Drug Addiction and the Opioid Crisis released its final report setting out 56 recommendations for addressing the national opioid crisis. The recommendations address issues such as federal funding and programs, opioid addiction prevention (e.g., prescribing guidelines, prescription drug monitoring programs, and supply reduction), overdose reversal, as well as research and development. Recommendation number 45 focuses on ways to connect overdose survivors to treatment and recovery services and alludes to the strategy of beginning medication assisted treatment in emergency rooms.

Federal law requires a practitioner who dispenses narcotic drugs for the treatment of opiate addiction to either register with the U.S. Drug Enforcement Administration or receive a DATA 2000 waiver from SAMHSA. However, the law does allow the emergency administration of narcotics absent registration or waiver to relieve acute withdrawal symptoms while treatment arrangements are being made (i.e., the three-day rule). Under the rule, an opioid agonist may be administered (but not prescribed) subject to the following conditions:

  • No more than one day’s medication may be administered to a person at one time.
  • The emergency treatment may not be carried out for more than three days.
  • The emergency treatment period of three days cannot be renewed or extended.

Some state health agencies have incorporated the three-day rule into their response to the opioid crisis. For example, in Maryland, the department of health identified approximately 24,000 emergency department visits for non-fatal overdoses annually. It also found that 58 percent of unintentional overdose death victims were seen in an emergency department for substance use disorder related-issues in the year prior to their fatal overdoses. Recognizing the potential of the emergency department as a venue for getting those with opioid dependency into treatment, the department of health established a program to incorporate screening, brief intervention, and referral to treatment in emergency department workflows, as well as utilization of the three-day rule, next day “warm hand off” to treatment providers, and peer support specialists to help bridge patients to recovery and treatment.

The Rhode Island Department of Health, in conjunction with the Department of Behavioral Healthcare and Hospitals Developmental Disabilities, developed a document called “Levels of Care for Rhode Island Emergency Departments and Hospitals for Treating Overdose and Opioid Use Disorder” to standardize the care of patients with opioid use disorder in the state’s emergency and hospital institutions. Level 1 and Level 2 facilities are expected to be able to provide emergency administration of opioid agonists, and the requirements of the three-day rule are set out in the standard criteria.

While the three-day rule adds to the strategies states and healthcare providers can use to assist those with opioid use disorder, there are a few limitations to the rule. These include the availability of treatment and recovery services and reimbursement issues. For additional information, please see ASTHO’s issue brief about the three-day rule.