Emergency department-initiated buprenorphine/naloxone treatment for opioid dependence: a randomized clinical trial.
OBJECTIVE
Opioid-dependent patients often use the emergency department (ED) for medical care.


OBJECTIVE
To test the efficacy of 3 interventions for opioid dependence: (1) screening and referral to treatment (referral); (2) screening, brief intervention, and facilitated referral to community-based treatment services (brief intervention); and (3) screening, brief intervention, ED-initiated treatment with buprenorphine/naloxone, and referral to primary care for 10-week follow-up (buprenorphine).


METHODS
A randomized clinical trial involving 329 opioid-dependent patients who were treated at an urban teaching hospital ED from April 7, 2009, through June 25, 2013.


METHODS
After screening, 104 patients were randomized to the referral group, 111 to the brief intervention group, and 114 to the buprenorphine treatment group.


METHODS
Enrollment in and receiving addiction treatment 30 days after randomization was the primary outcome. Self-reported days of illicit opioid use, urine testing for illicit opioids, human immunodeficiency virus (HIV) risk, and use of addiction treatment services were the secondary outcomes.


RESULTS
Seventy-eight percent of patients in the buprenorphine group (89 of 114 [95% CI, 70%-85%]) vs 37% in the referral group (38 of 102 [95% CI, 28%-47%]) and 45% in the brief intervention group (50 of 111 [95% CI, 36%-54%]) were engaged in addiction treatment on the 30th day after randomization (P < .001). The buprenorphine group reduced the number of days of illicit opioid use per week from 5.4 days (95% CI, 5.1-5.7) to 0.9 days (95% CI, 0.5-1.3) vs a reduction from 5.4 days (95% CI, 5.1-5.7) to 2.3 days (95% CI, 1.7-3.0) in the referral group and from 5.6 days (95% CI, 5.3-5.9) to 2.4 days (95% CI, 1.8-3.0) in the brief intervention group (P < .001 for both time and intervention effects; P = .02 for the interaction effect). The rates of urine samples that tested negative for opioids did not differ statistically across groups, with 53.8% (95% CI, 42%-65%) in the referral group, 42.9% (95% CI, 31%-55%) in the brief intervention group, and 57.6% (95% CI, 47%-68%) in the buprenorphine group (P = .17). There were no statistically significant differences in HIV risk across groups (P = .66). Eleven percent of patients in the buprenorphine group (95% CI, 6%-19%) used inpatient addiction treatment services, whereas 37% in the referral group (95% CI, 27%-48%) and 35% in the brief intervention group (95% CI, 25%-37%) used inpatient addiction treatment services (P < .001).


CONCLUSIONS
Among opioid-dependent patients, ED-initiated buprenorphine treatment vs brief intervention and referral significantly increased engagement in addiction treatment, reduced self-reported illicit opioid use, and decreased use of inpatient addiction treatment services but did not significantly decrease the rates of urine samples that tested positive for opioids or of HIV risk. These findings require replication in other centers before widespread adoption.


BACKGROUND
clinicaltrials.gov Identifier: NCT00913770.
Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut.
Gail
G
D'Onofrio
Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut.
Patrick G
PG
O'Connor
Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut.
Michael V
MV
Pantalon
Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut.
Marek C
MC
Chawarski
Yale School of Public Health, New Haven, Connecticut.
Susan H
SH
Busch
Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut.
Patricia H
PH
Owens
Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut.
Steven L
SL
Bernstein
Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut4Yale School of Public Health, New Haven, Connecticut.
David A
DA
Fiellin
D000328:Adult; D002047:Buprenorphine / Q000627:therapeutic use*; D004636:Emergency Service, Hospital; D005260:Female; D015658:HIV Infections / Q000453:epidemiology; D006296:Health Services / Q000706:statistics & numerical data; D006784:Hospitals, Teaching; D006786:Hospitals, Urban; D006801:Humans; D008297:Male; D009270:Naloxone / Q000627:therapeutic use; D009292:Narcotic Antagonists / Q000627:therapeutic use*; D009293:Opioid-Related Disorders / Q000188:drug therapy; D012017:Referral and Consultation; D012306:Risk; D055815:Young Adult
D009292:Narcotic Antagonists; D009270:Naloxone; D002047:Buprenorphine