With the opioid crisis continuing to grip the United States, the emergency department (ED) frequently finds itself at the forefront of dealing with the fallout, including treating patients with drug overdoses. It is also increasingly becoming a critical point for initiating treatment for those with opioid use disorder (OUD). A retrospective review recently published in the Journal of Emergency Medicine sheds light on a novel approach to buprenorphine induction for OUD in an ED setting, showing promise in bridging the gap between emergency care and long-term treatment solutions.
The study, titled “Retrospective Review of a Novel Approach to Buprenorphine Induction in the Emergency Department” (DOI: 10.1016/j.jemermed.2019.03.029), was spearheaded by a team of dedicated medical professionals at the Georgia Poison Center and the Department of Emergency Medicine at Emory University School of Medicine in Atlanta, Georgia.
The research involved a review of electronic medical records from patients seen at the Clinical Decision Unit (CDU) of a large county tertiary care center. These patients, all presenting with OUD, were treated between September 1, 2017, and February 6, 2018. Through a descriptive data summary, the researchers delved into an alternative model for managing OUD in emergency care.
The study’s focal point was the induction of buprenorphine-naloxone, a medication-assisted treatment (MAT) used for OUD. Induction is the first phase of MAT where the patient is transitioned from the opioid of abuse to the partial opioid agonist, buprenorphine, which helps alleviate withdrawal symptoms and cravings. This process usually requires careful monitoring to manage symptoms effectively.
Out of 18 different patients placed in the CDU during the study period, 95% were induced with buprenorphine-naloxone. This treatment took place in the controlled setting of the CDU—a bridge between the ED and inpatient care, which allows for longer observation periods without the need for full hospital admission.
Key Findings from the Review:
1. The median initial Clinical Opioid Withdrawal Scale (COWS) score, which is used to measure opioid withdrawal severity, was 10 at the time of induction, indicating moderate withdrawal symptoms.
2. The patients received a median total dose of 8/2 mg of buprenorphine-naloxone, aligning with recommended dosages for induction.
3. On average, patients spent a combined median time of 23 hours in the CDU and ED, demonstrating the availability of this unit for prolonged patient care and monitoring.
4. Post induction, approximately 63% (12 of 19) patients attended their initial follow-up appointment, which is crucial for continued treatment success.
5. Of those who attended their first follow-up session, nine patients remained active in the clinic after 30 days, and four continued with their treatment at the six-month mark.
These results demonstrate a significant rate of initial follow-up attendance, suggesting that induction of buprenorphine in the CDU setting may increase engagement with long-term treatment resources. The data also indicate that a subset of patients continued to engage with treatment services well beyond the induction phase.
Considering the gravity of the opioid epidemic, which has claimed hundreds of thousands of American lives, this novel buprenorphine induction approach could mark a pivotal shift in opioid dependency management. Interventions such as these directly address the continuity of care for patients with OUD after an ED visit, which has historically been a challenge.
Evidence from previous research already supports the induction of buprenorphine in the emergency department as a practical approach to OUD treatment. Studies have shown that patients initiated on MAT in the ED are more likely to be in treatment at 30 days compared to those who receive a referral to treatment without ED initiation.
The study, by Dunkley et al., is a monumental step towards solidifying the role of emergency medicine in handling the complexities associated with OUD. Moreover, introducing effective MAT in the fast-paced environment of the ED requires not only the development of novel treatment models but also encompasses training ED staff, addressing logistical issues, and integrating care with community-based treatment providers.
Looking forward, there are implications for public health policy and the allocation of resources, ensuring that emergency departments can fulfill this vital role in managing OUD. Establishing a successful induction protocol, as seen with the model in the review, can leverage the ED’s position as an access point for treatment initiation and potentially reduce the burden of opioid-related morbidity and mortality over time.
The supportive and multidisciplinary approach undertaken in this study aligns with a patient-centered treatment model that takes into account factors such as patient safety, effectiveness of the intervention, and the prospects of long-term recovery.
It must be noted, however, that this study comes with its limitations, primarily because of its retrospective nature and the small sample size. The results are promising but are not definitive. Larger-scale, prospective studies are needed to validate these findings and refine the protocols currently in use.
In conclusion, this retrospective review offers a glimpse into a practical and effective strategy for buprenorphine induction within an emergency department’s Clinical Decision Unit. The success of this approach could pave the way for more widespread adoption of similar models across emergency departments countrywide, providing a critical linkage from acute care settings to long-term treatment for individuals struggling with opioid use disorder.
References
1. Dunkley, C. A., Carpenter, J. E., Murray, B. P., Sizemore, E., Wheatley, M., Morgan, B. W., & Moran, T. P. (2019). Retrospective Review of a Novel Approach to Buprenorphine Induction in the Emergency Department. The Journal of Emergency Medicine, 57(2), 181-186. doi: 10.1016/j.jemermed.2019.03.029
2. D’Onofrio, G., O’Connor, P. G., Pantalon, M. V., Chawarski, M. C., Busch, S. H., Owens, P. H., … & Fiellin, D. A. (2015). Emergency department-initiated buprenorphine/naloxone treatment for opioid dependence: a randomized clinical trial. JAMA, 313(16), 1636-1644. doi: 10.1001/jama.2015.3474
3. Herring, A. A., Perrone, J., & Nelson, L. S. (2015). Managing Opioid Withdrawal in the Emergency Department With Buprenorphine. Annals of Emergency Medicine, 66(5), 449-451. doi: 10.1016/j.annemergmed.2015.07.010
4. Hawk, K., D’Onofrio, G., Fiellin, D. A., Chawarski, M. C., O’Connor, P. G., Owens, P. H., & Pantalon, M. V. (2017). A Research Agenda for Advancing Strategies to Improve Opioid Safety: Findings from a VHA State of the Art Conference. Journal of General Internal Medicine, 32(Suppl 1), 32-39. doi: 10.1007/s11606-017-3993-1
5. Kunins, H. V., & Farley, T. A. (2016). Use of Buprenorphine for Addiction Treatment: Perspectives of Addiction Specialists and General Psychiatrists. Psychiatric Services, 60(8), 1024-1032. doi: 10.1176/appi.ps.60.8.1024
Keywords
1. Buprenorphine induction ED
2. Medication-assisted treatment ER
3. Opioid use disorder emergency medicine
4. Buprenorphine-naloxone therapy
5. ED opioid withdrawal management