Why the ED?
Because that’s where the patients are!
The opioid epidemic is strongly impacting EDs, with 2018 data from the CDC indicating that there has been a 30% increase in visits for opioid overdose from July 2016 – September 2017.1 Addiction is a chronic, relapsing disease, and a strongly stigmatized one. It is NOT a moral failing. People who present to the ED for other chronic disease like diabetes and asthma are stabilized with medications and handed off for outpatient care. Individuals with opioid use disorder (OUD) and do best with a similar treatment plan.
Frequently Asked Questions
What is the evidence?
A 2015 study (JAMA) found that twice as many patients were in OUD treatment at 30 days (~80%) with ED-initiated buprenorphine & a brief negotiation interview (BNI) compared with referral only or a BNI + facilitated referral and used less illicit opioids in the last 7 days.2
What do I need to know about buprenorphine?
It is NOT simply replacing one drug for another
Buprenorphine treatment decreases withdrawal and craving. Patients who receive buprenorphine are less likely to OD, die, use illicit opioids, spread HCV or HIV and have fewer injection drug use complications and contacts with the criminal justice system.3 Since 2002 ED physicians can administer buprenorphine in the ED for opioid withdrawal. Within 30-45 minutes patients will be much more comfortable. MDs, PAs and APRNs who complete the DATA 2000 waiver training, can prescribe buprenorphine with referral to ongoing treatment.
Buprenorphine is a partial agonist at the mu opioid receptor, where it has a very high affinity but low intrinsic activity. Its high affinity means it will out-compete and displace full opioid agonists. It is administered when the patient exhibits withdrawal symptoms (COWS > 8). Its low intrinsic activity results in less euphoria and lower diversion potential.
- Vivolo-Kantor AM, Seth P, Gladden RM, et al. Vital Signs: Trends in Emergency Department Visits for Suspected Opioid Overdoses — United States, July 2016–September 2017. MMWR Morb Mortal Wkly Rep 2018;67:279–285. DOI: http://dx.doi.org/10.15585/mmwr.mm6709e1.
- D’Onofrio, G., O’Connor, P.G., Pantalon, M.V., Chawarski, M.C., Busch, S.H., Owens, P.H., Bernstein, S.L. and Fiellin, D.A., 2015. Emergency department–initiated buprenorphine/naloxone treatment for opioid dependence: a randomized clinical trial. JAMA, 313(16), pp.1636-1644.
- Mattick RP, Breen C, Kimber J, Davoli M. Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence. Cochrane Database of Systematic Reviews 2014, Issue 2. Art. No.: CD002207. DOI: 10.1002/14651858.CD002207.pub4
Articles of Interest
- Medication for Opioid Use Disorder After Nonfatal Opioid Overdose and Association With Mortality: A Cohort Study.Larochelle MR, Bernson D, Land T, Stopka TJ, Wang N, Xuan Z, Bagley SM, Liebschutz JM, Walley AY. Ann Intern Med. 2018 Aug 7; 2018 Jun 19. PMID: 29913516.
- Cost-effectiveness of emergency department-initiated treatment for opioid dependence.Busch SH, Fiellin DA, Chawarski MC, Owens PH, Pantalon MV, Hawk K, Bernstein SL, O'Connor PG, D'Onofrio G. Addiction. 2017 Nov; 2017 Aug 16. PMID: 28815789.
- Emergency Department-Initiated Buprenorphine for Opioid Dependence with Continuation in Primary Care: Outcomes During and After Intervention.D'Onofrio G, Chawarski MC, O'Connor PG, Pantalon MV, Busch SH, Owens PH, Hawk K, Bernstein SL, Fiellin DA. J Gen Intern Med. 2017 Jun; 2017 Feb 13. PMID: 28194688.
- Mortality risk during and after opioid substitution treatment: systematic review and meta-analysis of cohort studies.Sordo L, Barrio G, Bravo MJ, Indave BI, Degenhardt L, Wiessing L, Ferri M, Pastor-Barriuso R. BMJ. 2017 Apr 26; 2017 Apr 26. PMID: 28446428.
- Emergency department-initiated buprenorphine/naloxone treatment for opioid dependence: a randomized clinical trial.D'Onofrio G, O'Connor PG, Pantalon MV, Chawarski MC, Busch SH, Owens PH, Bernstein SL, Fiellin DA. JAMA. 2015 Apr 28. PMID: 25919527.
- Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence.Mattick RP, Breen C, Kimber J, Davoli M. Cochrane Database Syst Rev. 2014 Feb 6; 2014 Feb 6. PMID: 24500948.
- Psychosocial combined with agonist maintenance treatments versus agonist maintenance treatments alone for treatment of opioid dependence.Amato L, Minozzi S, Davoli M, Vecchi S. Cochrane Database Syst Rev. 2011 Oct 5; 2011 Oct 5. PMID: 21975742.