Level 2 (mid-level) evidence
Prescription opioid and heroin dependence is a major public health problem, with an estimated 15.6 million problem-opioid users worldwide (WHO 2009). Illicit opioid use is associated with a number of comorbidities and complications that may require the user to seek care in the emergency department (ED), making the ED an important link between dependent users and potential treatment options. Referral to addiction treatment programs is the most common option available to physicians encountering patients with opioid dependence in the ED. Brief interventions in primary care or ED settings have shown promise at reducing alcohol misuse (Ann Emerg Med. 2012;60:181-192; Cochrane Database Syst Rev. 2007;:CD004148), but it is unknown if similar interventions would be helpful for initiating treatment in patients with opioid dependence. A recent randomized trial compared 3 interventions in 329 patients (mean, age 31 years; 76% male) presenting to the ED with opioid dependence: treatment referral, brief intervention plus facilitated referral, and brief intervention plus ED-initiated buprenorphine/naloxone treatment plus referral (JAMA. 2015;313:1636-1644).
A 20-item health questionnaire was used to initially screen for opioid dependence in the previous 30 days, followed by the Mini-International Neuropsychiatric Interview and a urine sample of patients whose responses indicated non-medical opioid use in the past 30 days. Patients enrolled in formal addiction treatment programs were excluded, along with patients requiring hospitalization or requiring opioid medication for a pain condition. Patients randomly assigned to treatment referral received a handout about local addiction treatment services, whereas patients randomly assigned to the brief intervention plus facilitated referral had a 10- to 15-minute interview followed by a treatment referral, including a review of patient eligibility, insurance clearance, and transportation arrangement. Finally, all patients randomly assigned to the brief intervention plus ED-initiated buprenorphine/naloxone treatment received an interview followed by their first buprenorphine treatment in the ED if symptoms warranted, plus sufficient medication for home treatment until their follow-up appointment within 72 hours. This treatment group also received 10 weeks of buprenorphine treatment followed by a transfer for antagonist therapy maintenance or 2-week detoxification. The primary outcome was engagement in treatment, defined as patients enrolled in and receiving formal addiction treatment on day 30 after randomization.