Starting Buprenorphine in the Emergency Department

An interesting study in the April 28th Journal of the American Medical Association (JAMA) looked at three types of intervention for opioid addiction in patients presenting to the Emergency Department for care. It found that patients were more likely to be in addiction treatment and free from illicit opioids when started on buprenorphine in the emergency department, and given a referral to buprenorphine prescriber.

This study, done at an urban teaching hospital in Connecticut, screened patients in their emergency department and uncovered 329 patients with opioid addiction. Some came for help for the opioid addiction (34%) but the others came to the ER for other medical problems.

These patients were randomized to three interventions: one group was given written information about addiction treatment programs in the area. The second group was given this information, plus a brief intervention describing the various ways to treat opioid addiction. Patients in this group were linked with the referral and transportation to addiction treatment was arranged.

The third group had the same intervention as the second group, plus they were prescribed three days of buprenorphine, dosed at 8mg on day 1, and 16mg on days 2 and 3. Patients in this group were provided free office- based buprenorphine treatment for ten weeks, with visits ranging from several times per week to every two weeks, depending on how the patient was doing.

The study’s primary outcome was to compare how many patients in each of the three intervention groups were engaged in addiction treatment thirty days after their emergency department visit.

The results were what you would expect. People in the group that started actual treatment in the emergency department with buprenorphine were significantly more likely to be in addiction treatment thirty days later. In this group, 78% were in treatment. In the group given only treatment referrals, 37% were in treatment at 30 days, and 45% of the people given referral and brief intervention were engaged in treatment at 30 days.

Also, patients in the buprenorphine group reported greater reductions in the number of days of illicit opioid use than did the referral and brief intervention groups. The groups showed no significant difference in behaviors that increase risk for contracting HIV.

These patients were fairly ill, with high rates of co-occurring mental health disorders, with more than half reporting prior psychiatric diagnoses. About a fourth of these patients required acute care for a medical problem other than opioid addiction at their emergency department visit. These patients also had the expected high rates of concurrent other drug and alcohol use. In other words, these patients were about as ill as the average patient with opioid addiction.

However, this study didn’t include patients who were so sick that they required hospitalization, which may have skewed the data somewhat. Because services were free, this likely enhanced retention in treatment, though the authors say that 80% of all patients in the study were insured.
That’s an unusually high percentage, as compared with what I see in my rural area, in a state which did not expand Medicaid access.

The bottom line is that medication-assisted treatment with buprenorphine appears to be an effective way to get opioid-addicted patients into treatment and reduce illicit drug use in these patients. That would seem common sense, but we now have a study to support that assumption.

I love the idea of treatment being started in the emergency department, with close follow-up in an office setting or opioid treatment program. As the authors of this study pointed out, starting treatment for opioid addiction in the emergency department is very similar to how other chronic diseases are treated. For example, patients with new-onset diabetes or high blood pressure are often started on medication to treat the disorder in the emergency department, with a close follow up recommended with a primary care doctor.

Why do we treat the disease of addiction any differently?

My readers know the answer, of course: stigma and lack of education and understanding on the part of health care professionals.

As the authors pointed out in the discussion section of the study, even the referral group got more intervention than the average opioid addict visiting an emergency department in this country.

My patients still report being treated with derision and rudeness by emergency department staff. Not only are their medical problems including addiction not being addressed, they are shamed for being addicted. They are given powerful verbal and non-verbal messages that they are bad people, a pain in the ass to deal with, and unwelcome in the healthcare facility.

You could not invent a better recipe for continued drug addiction and avoidance of future medical care.

This study shows how easily this could be fixed. I would require emergency department doctors to get DATA 2000 certified, and the education of other healthcare professionals too. I don’t know how to initiate this solution but it can’t be done quickly enough.

I’ll say it again: we will know we are treating addiction well when it’s no longer easier to get drugs than treatment.