Emergency Department–initiated Interventions for Patients With Opioid Use Disorder: A Systematic Review

Abstract

Objectives: The opioid crisis has risen dramatically in North America in the new millennium, due to both illegal and prescription opioid use. While emergency departments (EDs) represent a potentially strategic setting for interventions to reduce harm from opioid use disorder (OUD), the absence of a recent synthesis of literature limits implementation and scalability. To fill this gap, we conducted a systematic review of the literature on interventions targeting OUDs initiated in EDs. Methods: Using an explicit search strategy (PROSPERO), the MEDLINE, CINAHL Complete, EMBASE, and EBM reviews databases were searched from 1980 to October 4, 2019. The gray literature was explored using Google Scholar. Study characteristics were abstracted independently. The methodologic quality and risk of bias were assessed. Results: Twelve of 2,270 studies met the inclusion criteria (two of high quality). In addition to the heterogeneity of the outcome measures used (retention in treatment, opioid consumption, and overdose), brief intervention and buprenorphine initiation (six of 12 studies) were the most documented with mixed effects for the former and positive short-term and confined to single ED sites effects for the latter. Conclusion: Emergency departments can be an appropriate setting for initiating opioid agonist treatment, but to be sustained, it likely needs to be coupled with community-based follow-up and support to ensure longer-term retention. The scarcity of high-quality evidence on OUD interventions initiated in emergency settings highlights the need for future research. O pioid use disorder (OUD) and opioid-related deaths have risen dramatically in North America in the new millennium and now reach epidemic proportions. 1,2 In the United States, opioid-related deaths increased by 345% from 9,489 to 42,245 between 2001 and 2016 (3.3 to 13.1 deaths per 100,000 population). 3 This crisis has reduced overall life expectancy in British Columbia, the Canadian province where the highest death rates have occurred. 4 In the past 3 years, the opioid-related deaths in Canada have

Emergency physician perspectives on initiating buprenorphine/naloxone in the emergency department: A qualitative study

“…12 A systematic review of ED-initiated interventions for patients with OUD found that OAT initiation, including BUP, was the most promising ED intervention; however, further research and efforts to reduce implementation barriers were recommended. 16…”

“…Because you know, these are patients with a history of overdose, history of criminality, history of diversion, you know they're not stable patients who you can give a prescription to and expect them to use it in any kind of responsible way." (participant16) Study participants thought that interphysician variability in motivation and ability to initiate BUP in the ED could be minimized by providing basic OAT training via accredited programs tailored specifically for emergency physicians. One participant explained: "I wish there was something that was perhaps a little bit shorter, or 1 specifically geared to emergency physicians.. .…”

Consensus Recommendations on the Treatment of Opioid Use Disorder in the Emergency Department

“…Evidence strongly supports the initiation of pharmacotherapy for patients with untreated opioid use disorder at any and all points of contact with the health care system; this has been advocated by the Surgeon General, the National Institute on Drug Abuse, the Substance Abuse and Mental Health Services Administration (SAMHSA), the National Academy of Sciences, and the American College of Emergency Physicians (ACEP). [24][25][26][27][28][29] The ED is often the only contact individuals with opioid use disorder have with the health care system, and initiating treatment during the visit can make an enormous contribution to improving access to lifesaving care for people with opioid use disorder.…”

Prevalence of Mental Health Disorders among Individuals Enrolled in an Emergency Response Program for Treatment of Opioid Use Disorder

“…23 Patients enrolled in treatment programs that included MOUD without behavioral health interventions and who were enrolled from the ED following a non-fatal overdose were less likely to be enrolled 30 days after initiation. 24,25 Individuals with co-occurring OUD and mental illness are more likely to continue using nonprescription opioids, 26 have increased risk of chronic and acute physical illness, 27 and are at increased risk of accidental 28 and intentional overdose, 29,30 thereby increasing opioid-related mortality. 31 A bulk of research on adults with co-occurring OUD and mental health over the past decade is largely based on national epidemiological surveys, 19,[32][33][34][35][36] retrospective data analysis, 2,[37][38][39] or surveys of individuals in treatment.…”

“…51,52 Individuals with mental health emergencies in the ED are triaged, stabilized, and released with a referral to community-based mental health services; 49,50,53 and this treat-andrefer model has largely continued with SUD emergencies. 49 Although ED-initiated MOUD is a promising approach to addressing the opioid crisis, 24,25 without prompt follow up with psychosocial services many patients fall through the cracks. 49 Previous research has reported the incidence of co-occurring serious mental illness among individuals with OUD to be anywhere from 26.9% 32 and the co-occurrence of any mental illness as high as 75.6%.…”