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Reference: JAMA 2015 Apr 28;313(16):1636 (level 2 [mid-level] evidence)
Prescription opioid and heroin dependence is a major public health problem, with an estimated 15.6 million problem opioid users worldwide (WHO 2009PDF). Illicit opioid use is associated with a number of comorbidities and complications that may require the user to seek care in the emergency department (ED), making the ED an important link between dependent users and potential treatment options. Referral to addiction treatment programs is the most common option available to physicians encountering patients with opioid dependence in the ED. Brief interventions in primary care or ED settings have shown promise at reducing alcohol misuse (Ann Emerg Med 2012 Aug;60(2):181, Cochrane Database Syst Rev 2008 Oct 8;(4):CD004148), but it is unknown if similar interventions would be helpful for initiating treatment in patients with opioid dependence. A recent randomized trial compared 3 interventions in 329 patients (mean age 31 years, 76% male) presenting to the ED with opioid dependence: treatment referral, brief intervention plus facilitated referral, and brief intervention plus ED initiated buprenorphine/naloxone treatment plus referral.
A 20-item health questionnaire was used to initially screen for opioid dependence in the past 30 days, followed by Mini-International Neuropsychiatric Interview and a urine sample of patients whose responses indicated non-medical opioid use in the past 30 days. Patients enrolled in formal addiction treatment programs were excluded, along with patients requiring hospitalization or requiring opioid medication for pain condition. Patients randomized to treatment referral received a handout about local addiction treatment services, while patients randomized to the brief intervention plus facilitated referral had a 10-15 minute interview followed by a treatment referral including a review of patient eligibility, insurance clearance, and transportation arrangement. Finally, all patients randomized to the brief intervention plus ED initiated buprenorphine/naloxone treatment received an interview followed by their first buprenorphine treatment in the ED if symptoms warranted, plus sufficient medication for home treatment until their follow-up appointment within 72 hours. This treatment group also received 10 weeks of buprenorphine treatment followed by a transfer for antagonist therapy maintenance or 2-week detoxification. The primary outcome was engagement in treatment, defined as patients enrolled and receiving formal addiction treatment on day 30 post-randomization.
The 30-day follow-up interview was completed by 74.2% of patients, but data on addiction treatment program enrollment at day 30 was available for 99% of patients and all patients were included in the primary outcome analysis. At day 30, patients receiving ED initiated buprenorphine treatment were significantly more likely to be engaged in treatment compared to patients receiving the brief intervention plus referral or a referral alone (78% vs. 45% vs. 37%, p < 0.001). Self-reported opioid use in past 7 days was also significantly lower with buprenorphine treatment, with mean number of days of use reported as 0.9 days with buprenorphine treatment vs. 2.4 days with the brief intervention plus referral vs. 2.3 days with referral alone (p < 0.001 across groups) and fewer patients in the buprenorphine group were receiving inpatient treatment. Of the 67% of patients providing urine samples, however, there were no significant differences in the rate of opioid negative urine toxicology between groups (57.6% with buprenorphine treatment vs. 42.9% with brief intervention plus referral vs. 53.8% with referral alone). There were also no significant differences between groups in HIV risk behaviors, outpatient addiction treatment visits, or the use of the ED for addiction treatment.
The results of this trial suggest that initiation of buprenorphine treatment in the emergency department with referral to a hospital-based primary care clinic may increase patient engagement in treatment and decrease self-reported opioid use within 30 days. This intervention was also associated with a reduction in the number of patients attending inpatient treatment programs, potentially reducing the cost of treatment. However, it is unknown if patients can be quickly and efficiently screened in busy emergency departments and if this treatment program can be replicated. Going beyond the usual ED referral and including a brief intervention along with a facilitated referral did not increase patient engagement or decrease opioid use compared to the standard referral alone, suggesting buprenorphine treatment may be the key to a successful intervention. In this trial, the buprenorphine was provided to patients at no cost and financial concerns, which may limit the use of ED-initiated buprenorphine treatment in other settings. Furthermore, physicians must undergo training before prescribing buprenorphine, which may inhibit some ED physician from participating in similar programs. It is also unknown whether this type of program could be successfully translated into the primary care setting, where physicians may also encounter patients with opioid dependence requiring treatment for addiction or other medical issues.
For more information, see the Opioid abuse or dependence topic in DynaMed.