More than two million Americans have an opioid abuse disorder.1 For each person who dies from an opiate overdose, many more require emergency care or hospitalization to survive. Central to the goal of reversing this epidemic is the challenging task of improving linkage to treatment for opioid-dependent patients. Despite strong clinical evidence, the use of buprenorphine-naloxone as maintenance therapy for opioid dependence remains low.
In this issue, D’Onofrio et al.2 explored whether emergency department (ED)-initiated buprenorphine-naloxone with continued primary care is better for promoting treatment engagement, deterring illicit drug use and reducing HIV risk behaviors over the long term (at 2, 6 and 12 months) than treatment referral only or a brief intervention with referral to treatment. Results of the study indicate that adult patients in the ED-initiated study arm were more likely to still be in treatment and to report less illicit opioid use at 2 months than those in the comparator arms.
Benefits of ED-initiated buprenorphine-naloxone treatment at the 2-month mark should be interpreted cautiously. First, the veracity of self-reported drug use may have been influenced by the fact that patients in the ED-initiated treatment arm were still receiving 10 weeks of continued care through the study. Second, there was no statistical difference in the urine toxicology test results across the three groups.
The absence of differences in any of the outcomes at the 6- and 12-month assessment points raises even broader questions regarding the discontinuation of buprenorphine-naloxone therapy and its associated consequences. Previous studies have shown that patients who use buprenorphine for 12 months are less likely to be hospitalized or to visit the ED than those who discontinue treatment within 5 months.3 Treatment barriers including scarcity of buprenorphine prescribers and coverage gaps have been well documented, particularly within marginalized groups.4 , 5
The results at the 2-month mark indicate that patients offered continued treatment were more likely to use it. This finding suggests the need for concerted efforts by clinicians, payers and policymakers alike to address not only the barriers to buprenorphine therapy initiation, but also the challenges that limit its continued use.
Compliance with Ethical Standards
Conflict of Interest
The author declares that she does not have a conflict of interest.
References
- 1.Center for Behavioral Health Statistics and Quality. Key substance use and mental health indicators in the United States: Results from the 2015 National Survey on Drug Use and Health (HHS Publication No. SMA 16-4984, NSDUH Series H-51). 2016.
- 2.D’Onofrio G, Chawarski MC, O’Connor PG, Pantalon MV, Busch SH, Owens PH, Hawk K, Bernstein SL, Fiellin DA. Emergency Department-initiated Buprenorphine for Opioid dependence with continuation in primary care: outcomes during and after intervention. J Gen Intern Med. doi:10.1007/s11606-017-3993-2. [DOI] [PMC free article] [PubMed]
- 3.Lo-Ciganic WH, Gellad WF, Gordon AJ, Cochran G, Zemaitis MA, Cathers T, Donohue JM. Association between trajectories of buprenorphine treatment and emergency department and in-patient utilization. Addiction. 2016;111(5):892–902. doi: 10.1111/add.13270. [DOI] [PubMed] [Google Scholar]
- 4.Abraham AJ, Knudsen HK, Rieckmann T, Roman PM. Disparities in access to physicians and medications for the treatment of substance use disorders between publicly and privately funded treatment programs in the United States. J Stud Alcohol Drugs. 2013;74(2):258–265. doi: 10.15288/jsad.2013.74.258. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Hansen H, Siegel C, Wanderling J, DiRocco D. Buprenorphine and methadone treatment for opioid dependence by income, ethnicity and race of neighborhoods in New York City. Drug Alcohol Depend. 2016;164:14–21. doi: 10.1016/j.drugalcdep.2016.03.028. [DOI] [PMC free article] [PubMed] [Google Scholar]