Emergency Department Intervention Improves Rate of Treatment for Opioid Dependence

 

Among opioid-dependent patients presenting for emergency care, treatment with buprenorphine initiated in the emergency department, compared with a brief intervention and referral, significantly increased the likelihood of receiving formal addiction treatment, reduced self-reported illicit opioid use, and decreased use of inpatient addiction treatment services but did not significantly decrease the rates of urine samples that tested positive for opioids or of HIV risk, according to a study in the April 28 issue of JAMA. Buprenorphine is a medication for opioid use disorder that decreases withdrawal symptoms, craving, and opioid use.

Dependence on prescription opioids and heroin is a major public health problem that is increasing in the United States and internationally. Opioid agonist treatment, including methadone and buprenorphine, is the most effective treatment. Patients with opioid dependence are at increased risk of adverse health consequences and often seek medical care in emergency departments (EDs). Currently, the primary option available to the ED for opioid dependence is referral to addiction treatment services. The introduction of buprenorphine/naloxone may provide ED physicians the opportunity to initiate effective medication treatment in conjunction with a brief intervention and referral, according to background information in the article.

Gail D’Onofrio, M.D., M.S., of the Yale School of Medicine, New Haven, Conn., and colleagues randomly assigned opioid-dependent patients who were treated at an urban teaching hospital ED to screening and referral to treatment (referral; n = 104); screening, brief intervention and facilitated referral (brief intervention; n = 111), or screening, brief intervention, ED-initiated treatment with buprenorphine/naloxone, and referral to primary care for 10-week follow-up (buprenorphine; n = 114).

The primary outcome for the study was enrollment in and receiving addiction treatment 30 days after randomization. Eighty-nine of 114 patients (78 percent) in the buprenorphine group were engaged in treatment at significantly higher rates than patients in the referral group (37 percent) or patients in the brief intervention group (45 percent). The buprenorphine group reported greater reductions in the average number of days of illicit opioid use per week—from 5.4 days to 0.9 days, compared to the referral group, which decreased from 5.4 days to 2.3 days, and the brief intervention group, which decreased from 5.6 days to 2.4.

The rates of opioid negative urine toxicology test results did not differ statistically across the treatment groups, with 54 percent in the referral group, 43 percent in the brief intervention group, and 58 percent in the buprenorphine group having tested negative for opioid use. There were no statistically significant differences in HIV risk across groups.

Eleven percent of patients in the buprenorphine group used inpatient addiction treatment services, whereas 37 percent in the referral group and 35 percent in the brief intervention group used these services.

“Our findings demonstrate that ED-initiated buprenorphine with coordinated follow-up for ongoing treatment was more effective than referral with or without brief intervention,” the authors write. “Although this single-site study supports this ED-initiated treatment strategy, these findings require replication in other centers before widespread adoption.”

(doi:10.1001/jama.2015.3474;