Opioid addiction treatment in the ED better than referrals

Emergency department (ED) patients with opioid dependence who receive a brief intervention and ED-initiated treatment with buprenorphine/naloxone and referral to primary care for 10-week follow up, are twice as likely to be engaged in addiction treatment at 30 days compared with standard referral and a brief intervention with a facilitated referral, according to a study published in JAMA.

Dr D'OnofrioPatients receiving buprenorphine are also more likely to reduce their self-reported use of illicit opioids at 30 days and less likely to use inpatient addiction services, according to the study led by Gail D’Onofrio, MD, MS, chair of emergency medicine at Yale School of Medicine.

Patients addicted to opioids often seek medical care in hospital EDs. Typically, after emergency care is given for an overdose, abscess, or other health issue, ED providers refer opioid-dependent individuals to addiction treatment.

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“Opioid addiction and overdose have reached epidemic proportions in the United States, and is a significant ongoing threat to the public’s health,” said Dr D’Onofrio. “Patients with opioid misuse, dependence, and overdose often use the emergency department for their source of care."

In a randomized clinical trial of 329 opioid-dependent patients enrolled in at Yale-New Haven Hospital Emergency Department, a large, urban teaching institution, patients were randomly assigned to 3 interventions: (1) screening and referral to treatment; (2) screening, brief intervention and facilitated referral to community-based treatment services; and (3) screening, brief intervention, ED-initiated treatment with buprenorphine, and referral to primary care for 10 weeks of medical management. Enrollment in and receiving addiction treatment at 30 days after randomization was the primary outcome. Self-reported days of illicit opioid use, urine testing for illicit opioids, HIV risk, and use of addiction treatment services were the secondary outcomes.

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“Untreated opioid dependence results in substantial costs to the healthcare system due to overdose, chronic viral infections [HIV and HCV], vascular infections, and prolonged and unnecessary hospitalizations,” said Dr D’Onofrio. “The study demonstrated that the best way to engage opioid-dependent patients who are seen in the emergency department for treatment is by providing buprenorphine/naloxone instead of a referral. Opioid-dependent patients who receive treatment have lower hospital utilization and total costs than patients who do not receive pharmacologic therapy.”

According to Dr D’Onofrio, formulary managers can ensure that buprenorphine/naloxone is available on their formularies and available in their emergency departments, that barriers to treatment initiation such as prior authorization are minimized, and provide potential prescribers with information on how to access the training required to prescribe the medication at http://www.buprenorphine.samhsa.gov/training_main.html

“Expanded use of an ED-initiated buprenorphine intervention increases access to treatment options for this chronic and relapsing condition with substantial morbidity and mortality,” Dr D’Onofrio added. “This innovative strategy expands the paradigm of initiating treatment in the ED and providing a facilitated referral to community services as currently provided for chronic diseases such as hypertension, diabetes, and asthma, to opioid dependence.”

This innovative strategy expands the paradigm of initiating treatment in the ED and providing a facilitated referral to community services as currently provided for chronic diseases such as hypertension, diabetes, and asthma, to opioid dependence.

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