Emergency Department-Initiated Buprenorphine/Naloxone Treatment for Opioid Dependence A Randomized Clinical Trial
Emergency Department-Initiated Buprenorphine/Naloxone Treatment for Opioid Dependence A Randomized Clinical Trial
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DOI：
10.1001/jama.2015.3474
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发表时间：
2015-04-28
影响因子：
120.7
通讯作者：
Fiellin, David A.
中科院分区：
文献类型：
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作者：
D'Onofrio, Gail;O'Connor, Patrick G.;Fiellin, David A.
重要性阿片类药物依赖患者经常使用急诊科（艾德）进行医疗护理。目的测试阿片类药物依赖的3种干预措施的效果：（1）筛查和转诊治疗（转诊）;（2）筛查、短暂干预和便利转诊到社区治疗服务（简短发言）;和（3）筛查、短暂干预、ED启动的丁丙诺啡/纳洛酮治疗，以及转诊至初级保健进行10周随访（丁丙诺啡）.设计、地点和参与者一项随机临床试验，包括329例阿片类药物依赖患者，他们于2009年4月7日至2013年6月25日在一家城市教学医院艾德接受治疗。干预筛选后，104例患者被随机分配到转诊组，111短暂的干预组，114丁丙诺啡治疗group.Main结果和措施登记和接受成瘾治疗后30天随机分组的主要结果。自我报告的非法阿片类药物使用天数、非法阿片类药物的尿液检测、人类免疫缺陷病毒（HIV）风险和成瘾治疗服务的使用是次要结局。（89/114 [95% CI，70%-85%]）对比转诊组的37%（102人中有38人[95%CI，28%-47%]），短暂干预组为45%（50/111 [95%CI，36%-54%]）在随机化后第30天进行成瘾治疗（P < .001）。丁丙诺啡组每周使用非法阿片类药物的天数从5.4天减少到2.5天。（95% CI，5.1-5.7）至0.9天（95% CI，0.5-1.3）vs从5.4天减少（95% CI，5.1-5.7）至2.3天（95% CI，1.7-3.0），从第5.6天开始在短期干预组中（95%CI，5.3-5.9）至2.4天（95%CI，1.8-3.0）（时间和干预效应P <0.001;交互效应P = 0.02）。阿片类药物检测阴性的尿液样本率在各组之间没有统计学差异，转诊组为53.8%（95% CI，42%-65%），短暂干预组为42.9%（95% CI，31%-55%），丁丙诺啡组为57.6%（95% CI，47%-68%）（P = 0.17）。各组之间的HIV风险没有统计学显著差异（P = 0.66）。丁丙诺啡组11%的患者（95% CI，6%-19%）使用住院成瘾治疗服务，而转诊组中有37%（95% CI，27%-48%），短期干预组为35%（95% CI，25%-37%）使用住院成瘾治疗服务结论和相关性在阿片类药物依赖患者中，ED启动的丁丙诺啡治疗与短暂干预和转诊相比，显著增加了成瘾治疗的参与，减少了自我报告的非法阿片类药物使用，减少了住院成瘾治疗服务的使用，但并未显着降低阿片类药物或艾滋病毒风险检测阳性的尿液样本的比率。这些发现需要在广泛采用之前在其他中心复制。
IMPORTANCE Opioid-dependent patients often use the emergency department (ED) for medical care.OBJECTIVE To test the efficacy of 3 interventions for opioid dependence: (1) screening and referral to treatment (referral); (2) screening, brief intervention, and facilitated referral to community-based treatment services (brief intervention); and (3) screening, brief intervention, ED-initiated treatment with buprenorphine/naloxone, and referral to primary care for 10-week follow-up (buprenorphine).DESIGN, SETTING, AND PARTICIPANTS A randomized clinical trial involving 329 opioid-dependent patients who were treated at an urban teaching hospital ED from April 7, 2009, through June 25, 2013.INTERVENTIONS After screening, 104 patients were randomized to the referral group, 111 to the brief intervention group, and 114 to the buprenorphine treatment group.MAIN OUTCOMES AND MEASURES Enrollment in and receiving addiction treatment 30 days after randomization was the primary outcome. Self-reported days of illicit opioid use, urine testing for illicit opioids, human immunodeficiency virus (HIV) risk, and use of addiction treatment services were the secondary outcomes.RESULTS Seventy-eight percent of patients in the buprenorphine group (89 of 114 [95% CI, 70%-85%]) vs 37% in the referral group (38 of 102 [95% CI, 28%-47%]) and 45% in the brief intervention group (50 of 111 [95% CI, 36%-54%]) were engaged in addiction treatment on the 30th day after randomization (P < .001). The buprenorphine group reduced the number of days of illicit opioid use per week from 5.4 days (95% CI, 5.1-5.7) to 0.9 days (95% CI, 0.5-1.3) vs a reduction from 5.4 days (95% CI, 5.1-5.7) to 2.3 days (95% CI, 1.7-3.0) in the referral group and from 5.6 days (95% CI, 5.3-5.9) to 2.4 days (95% CI, 1.8-3.0) in the brief intervention group (P < .001 for both time and intervention effects; P = .02 for the interaction effect). The rates of urine samples that tested negative for opioids did not differ statistically across groups, with 53.8% (95% CI, 42%-65%) in the referral group, 42.9%(95% CI, 31%-55%) in the brief intervention group, and 57.6%(95% CI, 47%-68%) in the buprenorphine group (P = .17). There were no statistically significant differences in HIV risk across groups (P = .66). Eleven percent of patients in the buprenorphine group (95% CI, 6%-19%) used inpatient addiction treatment services, whereas 37% in the referral group (95% CI, 27%-48%) and 35% in the brief intervention group (95% CI, 25%-37%) used inpatient addiction treatment services (P < .001).CONCLUSIONS AND RELEVANCE Among opioid-dependent patients, ED-initiated buprenorphine treatment vs brief intervention and referral significantly increased engagement in addiction treatment, reduced self-reported illicit opioid use, and decreased use of inpatient addiction treatment services but did not significantly decrease the rates of urine samples that tested positive for opioids or of HIV risk. These findings require replication in other centers before widespread adoption.