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Research question
Among adults with opioid use disorder seen in the emergency department, does starting buprenorphine there, compared with referral to treatment, increase engagement in addiction treatment and reduce illicit opioid use?
Search
CINAHL, PubMed and the Cochrane Library were searched using buprenorphine, emergency department, opioid use disorder and opioid dependence. Two key sources were selected: a randomized controlled trial of buprenorphine started in the emergency department, and a Cochrane systematic review of buprenorphine maintenance.
Findings
Emergency department–initiated buprenorphine (D'Onofrio et al., 2015). In a randomized trial of 329 opioid-dependent patients at an urban teaching hospital emergency department, patients were assigned to one of three groups: screening and referral; screening, brief intervention and facilitated referral; or screening, brief intervention, buprenorphine/naloxone started in the emergency department and 10 weeks of follow-up in primary care.
| Outcome at 30 days | Referral | Brief intervention | Buprenorphine |
|---|---|---|---|
| Engaged in addiction treatment | 37% | 45% | 78% |
| Days of illicit opioid use per week (from about 5.5 at baseline) | 2.3 | 2.4 | 0.9 |
Rates of opioid-negative urine tests did not differ significantly between groups.
Buprenorphine maintenance (Mattick et al., 2014). The Cochrane review included 31 trials with 5,430 participants. High-quality evidence showed that buprenorphine retained participants in treatment better than placebo at all doses studied, and moderate-quality evidence showed that only high doses (16 mg or more) suppressed illicit opioid use more than placebo. With flexible dosing, buprenorphine retained fewer participants than methadone, though suppression of opioid use was similar among those who stayed in treatment.
Synthesis
The trial shows that starting buprenorphine in the emergency department roughly doubles the share of patients engaged in treatment a month later, compared with referral, and reduces self-reported illicit opioid use. The Cochrane review supports the underlying treatment: buprenorphine keeps people in treatment and, at adequate doses, reduces opioid use. Together, they suggest that the emergency department visit is an opportunity to start effective treatment rather than only hand out a referral.
Appraisal
| Source | Strengths | Limitations |
|---|---|---|
| D'Onofrio et al. (2015) | Randomized; clear primary outcome; realistic setting | Single site; 30-day outcome; self-reported drug use; no difference in urine results |
| Mattick et al. (2014) | Large systematic review using Cochrane methods; graded evidence | Most trials outside emergency settings; few reported adverse events |
Gaps and implications
More research is needed on long-term outcomes after emergency department initiation, and on how well these programs work in rural emergency departments and for patients who use fentanyl. For practice, the evidence supports protocols for emergency department–initiated buprenorphine with guaranteed, rapid follow-up appointments. Nurses play key roles in screening, assessing withdrawal, teaching, and arranging the handoff to ongoing care.
References
D'Onofrio, G., O'Connor, P. G., Pantalon, M. V., Chawarski, M. C., Busch, S. H., Owens, P. H., Bernstein, S. L., & Fiellin, D. A. (2015). Emergency department–initiated buprenorphine/naloxone treatment for opioid dependence: A randomized clinical trial. JAMA, 313(16), 1636–1644. https://doi.org/10.1001/jama.2015.3474
Mattick, R. P., Breen, C., Kimber, J., & Davoli, M. (2014). Buprenorphine maintenance versus placebo or methadone maintenance for opioid dependence. Cochrane Database of Systematic Reviews, (2), Article CD002207. https://doi.org/10.1002/14651858.CD002207.pub4
