Opioid-dependent patients in ED need more than a treatment referral

Opioid dependence poses a huge public health problem in the United States, with patients often seeking care in the hospital emergency department (ED). Evaluation of patients for use of prescription or illicit opioids and then medical referral to addiction treatment has been the primary approach taken by health systems.

See also: Opioid overdoses straining hospital ERs

Now Yale researchers have tested three treatment strategies for patients with opioid dependence who seek care in the ED, according to a recent JAMA report.

Gail D’Onofrio, MD, MS, chair of emergency medicine at Yale School of Medicine, and her colleagues found that patients who were started on buprenorphine and referred for addiction treatment had better outcomes than those who received only a list of treatment services and those who received a brief psychological intervention and referral list.

“The patients who received ED-initiated medication and referral for ongoing treatment in primary care were twice as likely as the others to be engaged in treatment 30 days later,” D’Onofrio said in a news release. “They were less likely to use illicit opioids of any kind.”

In a randomized clinical trial, 329 opioid-dependent patients were voluntarily enrolled from April 2007, through June 2013, and randomly assigned to one of three management strategies for opioid addiction. The first group of 102 patients was screened and received referral to treatment services. The second group of 111 patients was screened, given a psychosocial intervention, and helped with a referral to a community-based treatment service. For the third group of 114 patients, ED physicians prescribed three days of treatment with buprenorphine to help with withdrawal symptoms and referred them to primary care for 10-week treatment with buprenorphine.

Results

In the buprenorphine group, 78% of the patients were still engaged in addiction treatment a month later, compared with 37% in the referral group and 45% in the brief intervention group with targeted referral. This was the primary outcome in the trial.

See also: Chronic pain meds misused by 20% to 25% of patients

Secondary outcomes of the study were self-reported illicit opioid use in the prior week (7 days), urine toxicology for illicit opioid use, HIV risk-taking behavior and sexual behavior, and use of addiction treatment services.

Researchers found a greater reduction in illicit opioid use during the preceding week among those who received ED-initiated buprenorphine (mean of 5.4 days to 0.9 days). The referral group reduced illicit opioid use during the previous 7 days from a mean of 5.4 days to 2.3 days, and the brief intervention group from a mean of 5.6 days to 2.4 days.

The negative opioid urine toxicology test results among the three groups were similar: 57.6% in the buprenorphine group, 42.9% in the brief intervention group, and 53.8% in the referral group. HIV risk-taking behavior was similar among the three groups.

Use of addiction treatment services demonstrated lower utilization of inpatient services among patients receiving buprenorphine at the ED.

A new model

“Patients in the referral and brief intervention groups used inpatient addiction treatment services at a higher rate than did those in the buprenorphine group: 37% in the referral group; 35% in the brief intervention group; and 11% in the buprenorphine group,” the authors wrote.

Patrick O’Connor, MD, MPH, professor of medicine and chief of general internal medicine at Yale School of Medicine, noted, “Effectively linking ED-initiated buprenorphine treatment to ongoing treatment in primary care represents an exciting new model for engaging patients who are dependent on opioids into state-of-the-art care.”

The physicians in the ED were trained to prescribe buprenorphine prior to the study. According to the authors, an ED that considers implementing this strategy for addiction treatment needs to establish a program for the correct diagnosis of opioid dependence. In addition, this clinical trial provided buprenorphine and patient counseling at no cost to the patients, although 80% of patients had health insurance coverage.

“In light of our findings, future research could be conducted to determine the extent to which reimbursement and coverage barriers impact treatment outcomes,” the authors said.