Opioid Use Disorders
Articles of Interest:
D’Onofrio G, O’Connor PG, Pantalon MV, et al. Emergency Department–Initiated Buprenorphine/Naloxone Treatment for Opioid Dependence: A Randomized Clinical Trial. JAMA. 2015;313(16):1636-1644. doi:10.1001/jama.2015.3474.
Opioid Use Disorders
BNI for Opioid Use Disorders
The Brief Negotiation Interview (BNI) and Emergency Department-Initiated Buprenorphine/Naloxone for Moderate/Severe Opioid Use Disorder is a screening and brief intervention and referral to treatment (SBIRT) model that was developed initially combined with ED-initiated buprenorphine treatment. While designed for use in hospital emergency departments (EDs) and its target population is ED patients > 18 years of age presenting for care with moderate/severe opioid use disorders, it can be used in any ambulatory healthcare setting. The intervention is designed to engage patients in treatment and expand urgently needed access to medication-assisted treatment.
The patient is screened for prescription opioid and heroin use as part of an overall health questionnaire. Those with a positive screen are evaluated for moderate/severe opioid use disorder using the Mini-International Neuropsychiatric Interview (MINI) or a similar diagnostic tool meeting DSM-5 criteria. Patients are eligible if they have a MINI > 3 and a positive urine test for opioids. The BNI can be implemented in 10-15 minutes, using motivational interviewing and cognitive behavioral strategies with the goal of achieving a patient-centered agreement for engaging in addiction treatment for opioid dependence.
The BNI consists of the following steps:
Establishing rapport with the patient and asking permission to discuss his or her opioid use. Current physical discomfort is discussed. Providing feedback by asking the patient if he or she sees a connection between their opioid use and the ED visit, or any other negative medical, psychological or social consequences. Information obtained in the MINI may be discussed. Finally the patient is informed about ongoing buprenorphine treatment options beyond the ED.
Enhancing motivation to engage in addiction treatment post ED discharge by asking how ready they are to engage in buprenorphine treatment, using a scale from 1 to 10; 1 is not at all ready to engage and 10 is totally ready to engage. Depending on the response, the interventionist asks why the patient did not state a lower number, eliciting positive reasons or motivations for engagement. These statements are then restated to the patient using reflective listening skills.
Negotiate next steps for engaging in buprenorphine treatment post-ED by reviewing and reinforcing his or her motivation, removing any obstacles, setting goals, and facilitating the first appointment once a referral agreement is signed.
ED-initiated treatment with buprenorphine is administered to patients exhibiting moderate/severe opioid withdrawal in the ED. Take-home daily doses are then provided as needed until their first provider or community-based treatment program appointment within 72 hours.
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