ED Suboxone Results in Increased Engagement in Addiction Treatment, Reduced Opioid Use
The emergency department provides opportunities to screen for opioid use disorder, provide interventions, and facilitate referral to ongoing treatment. Two published reports (from 2015 and 2017) out of Yale School of Medicine shows positive outcomes when emergency departments provide buprenorphine/naloxone (Suboxone) for addiction treatment with continuation in primary care.
Using this paradigm, the 2015 report showed that opioid use disorder patients who were treated with buprenorphine/naloxone were more likely to be engaged in formal addiction treatment at 30 days after their ED visit than those given only a brief intervention or referral without the drug. The 2017 report demonstrated that the relative benefit of emergency department-initiated buprenorphine/naloxone with referral for ongoing treatment in primary care persisted at 2 months. The findings at 2 months in the buprenorphine/naloxone treatment group were consistent with those of other studies of primary care office-based buprenorphine/naloxone treatment for opioid dependence.
The 2015 report can be accessed at: D’Onofrio, G., et al. “Emergency department-initiated buprenorphine/naloxone treatment for opioid dependence.” JAMA 2015; 313(16):1636-1644.
The 2017 report can be accessed at: D’Onofrio, et al. “Emergency department-initiated buprenorphine for opioid dependence with continuation in primary care: outcomes during and after intervention.” J Gen Intern Med 2017; 32(6):660-6.
Opioid-dependent patients often use the emergency department for medical care. The availability of buprenorphine/naloxone (U.S. brand name Suboxone), a partial opioid agonist combined with an antagonist, may provide emergency department physicians the opportunity to initiate effective medication treatment in conjunction with a brief intervention and referral.
Buprenorphine/naloxone is supplied as a prescription oral (tablet) dose form that decreases withdrawal, craving, and opioid use.
This study was designed to test the efficacy of three types of treatments for opioid dependence:
- Screening and referral to treatment
- Screening, brief intervention, and referral to community-based treatment services
- Screening, brief intervention, emergency department-initiated treatment with buprenorphine/naloxone, and referral to primary care for 10-week follow-up
Under Option 1, after undergoing screening, referral patients received a handout from a research associate providing names, locations, and telephone numbers of addiction treatment services in the area, and telephone access to call a facility of their choice.
Under Option 2, after undergoing screening, the “brief intervention” patients' experience included a 10-to-15-minute, manual-driven, audio-taped negotiation interview from a research associate. Then the research associate directly linked the patient with an addiction treatment service, including reviewing the patient’s eligibility for services, insurance clearance, and arranging transportation.
Under Option 3, after undergoing screening and the same brief intervention as described in Option 2, the patient also received treatment in the emergency department with buprenorphine/naloxone if they exhibited moderate-to-severe symptoms of opioid withdrawal. Take-home daily doses of buprenorphine/naloxone were provided to ensure the patient had enough medication until a scheduled appointment in the hospital’s primary care center within 72 hours. Patients were prescribed 8 mg for day 1 and 16 mg on days 2 and 3. For patients not manifesting opioid withdrawal in the emergency department, the drug was provided for unobserved consumption with a detailed medication guide.
Office-based buprenorphine/naloxone treatment was provided for 10 weeks by physicians and nurses using established procedures with visits ranging from weekly to twice monthly based on clinical stability. After the 10-week period, patients were transferred for ongoing maintenance treatment to either a community program or to a clinician.
- 78% of patients in the buprenorphine/naloxone group (89 of 114) vs 37% in the referral group (38 of 102) and 45% in the brief intervention group (50 of 111) were engaged in addiction treatment on the 30th day after start of respective treatments
- The buprenorphine/naloxone group reduced the number of days of illicit opioid use per week from 5.4 days to 0.9 days vs a reduction from 5.4 days to 2.3 days in referral group and from 5.6 days to 2.4 days in the brief intervention and referral group
- The rates of urine samples that tested negative for opioids did not differ statistically across groups: 57.6% in buprenorphine/naloxone group, 53.8 % in referral group, and 42.9 % in brief intervention-referral group
Among opioid-dependent patients, emergency department-initiated buprenorphine/naloxone treatment significantly increased engagement in addiction treatment, reduced self-reported illicit opioid use, and decreased use of inpatient addiction treatment services over merely providing brief intervention and referral. However, the drug did not significantly decrease the rates of urine samples that tested positive for opioids.
Patients receiving emergency department-initiated buprenorphine/naloxone with continuation in primary care were more likely to be engaged in formal addiction treatment at 30 days than those in the brief intervention or referral groups. The authors commented that the findings provide a new paradigm for emergency department-initiated treatment of patients with moderate/severe opioid use disorder.
The authors of the 2017 report stated that since it was unknown how long the benefits of emergency department-initiated buprenorphine/naloxone with continuation therapy in primary care will last, there was the need to evaluate the long-term outcomes at 2, 6 and 12 months following emergency department interventions.
Interventions were similar to the 2015 study as described above and included:
- Screening and referral to treatment
- Screening, brief intervention, and referral to treatment
- Screening, brief intervention, emergency department-initiated treatment with buprenorphine/naloxone, and referral to primary care for 10-week continuation of medication therapy
Patients received emergency department-initiated buprenorphine/naloxone if they exhibited moderate-to-severe opioid withdrawal. Enough take-home daily doses were provided to ensure they had adequate amounts until a scheduled appointment in the hospital’s primary care center within 72 hours. Patients were prescribed 8 mg for day 1 and 16 mg on days 2 and 3. For the patients not exhibiting opioid withdrawal in the emergency department (57%), enough drugs were provided for home induction, along with a detailed self-medication guide.
Primary care-based buprenorphine/naloxone treatment was continued for 10 weeks, with visits ranging from weekly to twice monthly. After 10 weeks, all patients were offered referral for transitioning to an opioid agonist treatment program. For patients who requested it, a detoxification program over a 2-week period was provided along with a referral for ongoing care consisting of naltrexone and counseling.
Long-term follow-up assessments at 2 and 6 months were completed primarily face-to-face (88% and 82%) and by telephone (12% and 18%) by trained research associates in a clinical setting separate from treatment sites. The 12-month assessment was completed primarily by phone (84% phone, 16% face-to-face).
Patients who completed face-to-face interviews at 2 and 6 months also provided urine samples for drug screening for opioid metabolites.
The main measures were self-reported engagement in formal addiction treatment, days of illicit drug use, and HIV risk at the 2-, 6- and 12-month evaluations. Urine toxicology was measured at 2 and 6 months.
- 33% were seeking treatment for opioid dependence at the initial visit
- 9% presented with an overdose
- Remaining 58% were identified through screening
Engagement in formal addiction treatment
- Buprenorphine/naloxone group had significantly more patients receiving formal addiction treatment at the 2-month assessment (74%) compared with referral (53%) or brief intervention groups (47%)
- There were no significant differences between the buprenorphine/naloxone (53%), referral (60%), and brief intervention (51%) groups at 6 months
- There were no differences between the buprenorphine/naloxone (49%), referral (49%), and brief intervention (51%) groups at 12 months
Illicit opioid use and HIV risk behaviors
- At 2 months, the buprenorphine/naloxone group reported fewer days of illicit opioid use [1.1 (95% CI 0.6-1.6)] versus referral [1.8 (95% CI 1.2-2.3)] and brief intervention [2.0 (95% CI 1.5-2.6)]
- There was a significant temporal trend toward reduction in illicit opioid use in all groups from baseline to 12 months, but no longer any differences between groups
- There were no significant differences among the three groups regarding HIV risk behaviors at any of the assessment points
- Rates of illicit opioid-negative urine tests were not significantly different at 2 months in the buprenorphine/naloxone group (62.7%), the referral group (59.2%), and the brief intervention group (58.6%)
- Negative urine test rates were also similar at 6 months in all three groups: buprenorphine/naloxone group (63.5%), referral (55.9%), and brief intervention (52.5%)
The study demonstrated that the relative benefit of ED-initiated buprenorphine/naloxone with referral for ongoing treatment in primary care persists at 2 months. The findings at 2 months in the buprenorphine/naloxone treatment group were consistent with those of other studies of primary care office-based buprenorphine/naloxone treatment for opioid dependence.
The emergency department visit is an opportunity to engage patients with opioid use disorder in effective medication-assisted treatment. Ongoing research should focus on evaluating the implementation of this model in a diverse array of emergency departments and other healthcare settings.
Richard L. Wynn, BS Pharm, PhD, is professor of pharmacology at the Baltimore College of Dental Surgery, Dental School, University of Maryland Baltimore.
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