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; Available pre-embargo to the media at http://media.jamanetwork.com)
Editor’s Note: The study was supported by a grant from the National Institute on Drug Abuse (NIDA), and Reckitt-Benckiser Pharmaceuticals provided buprenorphine through NIDA. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, etc.