Emergency Department-Initiated Buprenorphine/Naloxone Beneficial When Prolonged
Opiate use disorder was found to be more prevalent in patients who had presented to emergency departments than in the general population.
Buprenorphine/naloxone treatment initiated in the emergency department (ED) and prolonged for 10 weeks in primary care improved treatment engagement and reduced opioid use compared with referral or brief intervention.1
"This study represents a new paradigm for ED-initiated treatment of opioid use disorder with referral for ongoing care," stated lead investigator Gail D'Onofrio, MD, in an interview with Clinical Pain Advisor. She noted that the approach tested in the study, in which an ED clinician initiates treatment and refers patients for follow-up, is similar to that used in other chronic disorders such as hypertension or hyperglycemia. Opiate use disorder was found to be more prevalent in patients who had presented to emergency departments than in the general population.2
The study presented a long-term follow-up of outcomes from the investigators' previous work published in JAMA.3 The JAMA study randomly assigned 329 opioid-dependent patients to 1 of 3 interventions: screening and referral to treatment (referral); screening, brief intervention, and facilitated referral to community-based treatment services (brief intervention); or screening, brief intervention, ED-initiated treatment with buprenorphine/naloxone, and referral to primary care for 10 weeks of continued buprenorphine/naloxone treatment (buprenorphine).
Results of this study showed that at 30 days after treatment randomization, patients in the buprenorphine group were more likely to be involved in addiction treatment than those who received the other interventions. In addition, self-reported illicit opioid use and use of inpatient addiction treatment services were less prevalent in patients who had been prescribed buprenorphine than in patients in the other 2 groups.
The current study involved 88% of the same patients (n=329) who contributed data at a minimum of 1 follow-up assessment conducted at 2, 6, and/or 12 months after the ED intervention. Results showed that at 2 months, engagement in addiction treatment was more common in the buprenorphine group (68/92 [74%]; 95% CI, 65-83) than in those who received referral (42/79 [53%]; 95% CI, 42-64) or brief intervention (39/83 [47%]; 95% CI, 37-58; P <.001). Patients randomly assigned to buprenorphine had fewer self-reported days of illicit opioid use (1.1; 95% CI, 0.6-1.6) compared with the referral group (1.8; 95% CI, 1.2-2.3) or the brief intervention group (2.0; 95% CI, 1.5-2.6; P =.04]. No statistically significant differences for those outcomes were present at 6- or 12-month follow-ups.
Dr D'Onofrio told Clinical Pain Advisor that her research group hoped to offer alternative best practices to emergency physicians, who are not typically involved with continued care of patients with opioid use disorders. "Most EDs observe patients after recovery from overdose, but discharge them with at best a list of programs in the community for help. They do not make direct linkages to treatment programs or providers and do not initiate buprenorphine, similar to when patients present with any other problem related to opioid use disorder," she said.
Summary and Clinical Applicability
The researchers noted that despite its limitations, the study indicates that ED-initiated buprenorphine/naloxone treatment combined with referral for ongoing treatment in primary care is effective at increasing participation in addiction treatment and reducing self-reported illicit opioid use while treatment is continued. "For 27% of the enrolled ED patients, the index ED visit represented their first treatment contact," they wrote. "Thus, the ED visit is an opportunity to engage patients with opioid use disorder in effective medication-assisted treatment."
- The study was conducted at only 1 ED and 1 site for primary care, both in the same academic medical center, and thus may not be generalizable to other settings.
- Thirty-nine patients of the original cohort were not included in the follow-up.
- Data on engagement in addiction treatment were based on self-reports and not confirmed with providers.
- Engagement in treatment was assessed at designated times, potentially leading to an underestimation, as patients may have been involved in treatment at other times.
- D'Onofrio G, Chawarski MC, O'Connor PG, et al. Emergency department-initiated buprenorphine for opioid dependence with continuation in primary care: outcomes during and after intervention [published online February 13, 2017]. J Gen Intern Med. doi: 10.1007/s11606-017-3993-2
- Wu L-T, Swartz MS, Wu Z, Mannelli P, Yang C, Blazer DG. Alcohol and drug use disorders among adults in emergency department settings in the United States. Ann Emerg Med. 2012;60(2):172-180. doi: 10.1016/j.annemergmed.2012.02.003
- D'Onofrio G, O'Connor PG, Pantalon MV, et al. Emergency department-initiated buprenorphine/naloxone treatment for opioid dependence: a randomized clinical trial. JAMA. 2015;313(16):1636-1644. doi: 10.1001/jama.2015.3474