The 30-day follow-up interview was completed by 74.2% of patients, but data on addiction treatment program enrollment at day 30 was available for 99% of patients, and all patients were included in the primary outcome analysis. At day 30, patients receiving ED-initiated buprenorphine treatment were significantly more likely to be engaged in treatment compared to patients receiving the brief intervention plus referral or a referral alone (78% vs. 45% vs. 37%; P < 0.001). Self-reported opioid use in the past 7 days was also significantly lower with buprenorphine treatment, with mean number of days of use reported as 0.9 days with buprenorphine treatment vs. 2.4 days with the brief intervention plus referral vs. 2.3 days with referral alone (P<0.001 across groups), and fewer patients in the buprenorphine group were receiving inpatient treatment. Of the 67% of patients providing urine samples, however, there were no significant differences in the rate of opioid-negative urine toxicology between groups (57.6% with buprenorphine treatment vs. 42.9% with brief intervention plus referral vs. 53.8% with referral alone). There were also no significant differences between groups in HIV risk behaviors, outpatient addiction treatment visits, or the use of the ED for addiction treatment. 

The results of this trial suggest that initiation of buprenorphine treatment in the emergency department with referral to a hospital-based primary care clinic may increase patient engagement in treatment and decrease self-reported opioid use within 30 days. This intervention was also associated with a reduction in the number of patients attending inpatient treatment programs, potentially reducing the cost of treatment. However, it is unknown if patients can be quickly and efficiently screened in busy emergency departments and if this treatment program can be replicated. Going beyond the usual ED referral and including a brief intervention along with a facilitated referral did not increase patient engagement or decrease opioid use compared to the standard referral alone, suggesting buprenorphine treatment may be the key to a successful intervention. In this trial, the buprenorphine was provided to patients at no cost, which may limit the use of ED-initiated buprenorphine treatment in other settings. Furthermore, physicians must undergo training before prescribing buprenorphine, which may inhibit some ED physicians from participating in similar programs. It is also unknown whether this type of program could be successfully translated into the primary care setting, where clinicians may also encounter patients with opioid dependence requiring treatment for addiction. 

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Alan Ehrlich, MD, is a deputy editor for DynaMed, in Ipswich, Mass., and assistant clinical professor in Family Medicine, University of Massachusetts Medical School in Worcester.

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