ED-Initiated Buprenorphine Helps Opioid Addicts Recover

Megan Brooks

May 01, 2015

The emergency department (ED) is an ideal place to have opioid addicts get started on buprenorphine therapy ― and the road to recovery, new research suggests.

In a study conducted at Yale–New Haven Hospital, in Connecticut, ED-initiated buprenorphine therapy and referral to primary care improved opioid-dependent patients' engagement in treatment at 30 days, decreased illicit opioid use, and reduced use of inpatient services.

The study was published online April 28 in JAMA.

Opioid addiction has reached "epidemic proportions" in the United States, the researchers, led by Gail D'Onofrio, MD, said in a JAMA podcast.

"The ED is often the place that opioid-dependent patients seek their care, so it makes sense this would be the place where we would try to screen and intervene for this very significant problem," she added.

The study team enrolled 329 opioid-dependent patients presenting to their ED and randomly assigned them to one of three interventions: screening and referral to treatment (referral group, n = 104); screening, a brief intervention to motivate them to seek care, and facilitated referral to community-based treatment services (brief intervention group, n = 111); or screening, brief intervention, and ED-initiated buprenorphine/naloxone therapy with referral to primary care for a 10-week course of maintenance buprenorphine (buprenorphine group, n = 114).

These were "complicated patients," Dr D'Onofrio noted, in that many had used other drugs, including cocaine, cannabis, and sedatives, and had a history of psychiatric treatment.

ED-initiated buprenorphine therapy was clearly more effective than the other two strategies, with almost twice as many patients in the buprenorphine group still engaged in treatment at 30 days (the primary outcome).

Group In Treatment at 30 Days
Buprenorphine 78% (95% CI, 70% - 85%)
Referral 37% (95% CI, 28% - 47%)
Brief intervention 45% (95% CI, 36% - 54%)

CI, confidence interval.

 

The buprenorphine group had greater reductions in the average number of days of illicit opioid use per week, from 5.4 days to 0.9 days, compared with 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.

There were no marked differences in rates of opioid-negative urine samples (57.6% in the buprenorphine group vs 53.8% in the referral group and 42.9% in the brief intervention group).

Fewer people in the buprenorphine group used inpatient treatment (11% vs 37% in the referral group vs 35% in the brief intervention group).

"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."

"Our next step," Dr D'Onofrio said, "is to expand the study beyond Yale New Haven Hospital."

"Buprenorphine does require special training and a waiver from the US Food and Drug Administration in order to prescribe it, which does set some barriers up," she noted. "We are, as emergency physicians, able to give out a dose in the ED to decrease withdrawal symptoms and to refer. However, in order to prescribe more than that, we do need a waiver, so there are some barriers that still need to be overcome."

A "Reachable" Moment

This is an "innovative" approach, Jeffrey Samet, MD, MPH, of the Boston University School of Medicine Clinical Addiction Research and Education Unit and the Boston Medical Center, told Medscape Medical News.

"Anytime we can engage patients to begin to address their addiction to opioids is super. The ED is a place where people who don't want to come in for medical care come in for medical care because something is pushing the issue, and we know one of the biggest problems in getting people addiction treatment is having them show up," Dr Samet added. Seeing an opioid-dependent patient in the ED provides a "reachable moment for people who are very hard to reach," he said.

This study compared three "very reasonable strategies," Dr Samet noted. He admitted he was "surprised" by the cautionary tone of the study's conclusion. "If I was the head of an emergency department and saw this study and the high quality of the scientific methods, I would have it as part of the menu of options," he said.

The study was supported by the National Institute on Drug Abuse (NIDA). Reckitt-Benckiser Pharmaceuticals provided buprenorphine through the NIDA. One author has received honoraria from Pinney Associates for serving on an external advisory board monitoring the diversion and abuse of buprenorphine. No other relevant financial relationships were reported.

JAMA. 2015;313:1636-1644. Abstract

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