Best Practices for Substance Use Screening and Treatment in the Emergency Department
SEMINAL STUDY
9.5
9.4 // Mental Health & Substance Use
9.6 // Opioid Use Disorder Treatment in the ED
9 BEHAVIORAL HEALTH
Disclosures
No relevant disclosures or conflicts of interest to disclose
Learning objectives
Epidemiology and costs
Nearly half of all emergency department (ED) visits in the US are related to substance use disorders (SUD)
More than 20 million Americas ages 12 and older have an SUD yet only a minority receive addiction treatment
SUD-related costs related to productivity, healthcare, and crime exceed 400 billion dollars per year
Despite increasing rates of ED visits for SUD and fatal overdoses during the COVID pandemic, evidence-based treatments remain under-utilized
Screening questions for substance use disorders
The ED visit is an opportunity to screen for SUD, initiate behavioral and pharmacological interventions, and link patients to longitudinal treatment
Validated ED-appropriate screening tools are available for alcohol (AUDIT-C, the CAGE questionnaire, NIAAA single-question screen) and SUD (e.g., DAST, NIDA)—including tobacco
Screening questions for substance use disorders
NIAAA (alcohol): “How many times in the past year have you had 5 [men] or 4 [women, elderly] or more drinks in a day?
NIDA Quick Screen Single drug use question: “How many times in the past year have you used an illegal drug or used a prescription medication for nonmedical reasons? (100% sensitive, 74% specific for drug use disorder (DUD) in primary care settings)
Screening questions for substance use disorders
Motivational interviewing
ED visits are “teachable moments” to reduce complications from SUD
Brief ED interventions based on motivational interviewing (MI) in may facilitate behavioral change through a 4-step process—engaging, focusing, evoking, planning
MI based on empathetic, nonjudgmental open questions, reflective listening, and summarizing
Studies in ED settings show mixed results, likely from heterogeneous methods and populations
Interventions for alcohol: gauging risk
Spectrum of alcohol use:
Interventions for alcohol
Goals: reduce frequency/quantity, prevent injury (e.g., driving), engage in AUD treatment (improved with direct transfer to treatment facility)
Brief ED interventions show reductions in injuries, return ED visits (moderate quality evidence)
MI-based intervention (e.g., Brief Negotiated Interview) may decrease frequency and consumption
Systematic review of ED interventions showed 41% reduced odds of alcohol-related injury at 6 and 12 months
Screening, brief intervention, and referral to treatment (SBIRT) for alcohol may reduce healthcare costs
Interventions for opioid and illicit drug use
Evidence for SBIRT for DUD more limited than AUD
Brief interventions show decreases in overdose risk behaviors and non-medical opioid use, and increased treatment engagement
Brief intervention for opioid use disorder (OUD) and ED-initiated buprenorphine associated with decreased opioid use and cost-effectiveness
Interventions for tobacco
Evidence for ED-initiated interventions weak to moderate quality
May increase tobacco abstinence at 1 month
Higher abstinence rates when combining brief intervention, nicotine replacement therapy, and quitline referral
ED pharmacological interventions for substance use disorders
Peer recovery coaching
Peers in addiction treatment trained in MI may facilitate transitions to longitudinal care and sustain engagement
One observational study demonstrated shorter time to new OUD medication start when ED patients got a peer recovery coach, though overall uptake was slower
A 2022 RCT showed no difference in treatment engagement at 30 days between peer-led and social work interventions for ED patients with recent opioid overdose
Treatment referral for substance use disorders
Linkage to SUD treatment after discharge is facilitated by designated ED clinical champions and formal protocol for warm handoff to community providers
Best practices for treatment linkage include automated EHR-embedded processes, multiple referral options, and encrypted referral messaging (EHR, email, fax)
Harm reduction principles
Harm reduction: strategies and practices by and for people who use drugs to reduce their risks (e.g., overdose, HIV, HCV, skin infections)
Given the prevalence of fentanyl and its analogs in the unregulated drug supply, opioid overdose risk is not restricted to people with OUD
Harm reduction interventions
*May be limited by local/state paraphernalia laws
Assessment questions
All of the following are evidence-based pharmacological treatments for substance use disorders except
Assessment questions
All of the following are evidence-based pharmacological treatments for substance use disorders except
Assessment questions
All of the following are associated with reduced harm from risky substance use except
Assessment questions
All of the following are associated with reduced harm from risky substance use except
References
Hawk, K., & D'Onofrio, G. (2018). Emergency department screening and interventions for substance use disorders. Addict Sci Clin Pract, 13(1), 18.
Chua, K. P., Dahlem, C. H. Y., Nguyen, T. D., Brummett, C. M., Conti, R. M., Bohnert, A. S., Dora-Laskey, A. D., & Kocher, K. E. (2022). Naloxone and Buprenorphine Prescribing Following US Emergency Department Visits for Suspected Opioid Overdose: August 2019 to April 2021. Ann Emerg Med, 79(3), 225-236. https://doi.org/10.1016/j.annemergmed.2021.10.005
Barata, I. A., Shandro, J. R., Montgomery, M., Polansky, R., Sachs, C. J., Duber, H. C., Weaver, L. M., Heins, A., Owen, H. S., Josephson, E. B., & Macias-Konstantopoulos, W. (2017). Effectiveness of SBIRT for Alcohol Use Disorders in the Emergency Department: A Systematic Review. West J Emerg Med, 18(6), 1143-1152. https://doi.org/10.5811/westjem.2017.7.34373
CA Bridge (2023). Resources. Retrieved May 3, 2023 from https://cabridge.org/tools/resources/
Herring, A. A., & Kaleekal, J. (2022). Bridge for Meth: Multi-Center Prospective Evaluation of Emergency Department Initiation of Mirtazapine for Problematic Methamphetamine Use [ABSTRACT]. Ann Emerg Med, 80(4). https://doi.org/https://doi.org/10.1016/j.annemergmed.2022.08.052
References
Trivedi, M. H., Walker, R., Ling, W., Dela Cruz, A., Sharma, G., Carmody, T., Ghitza, U. E., Wahle, A., Kim, M., Shores-Wilson, K., Sparenborg, S., Coffin, P., Schmitz, J., Wiest, K., Bart, G.,
Sonne, S. C., Wakhlu, S., Rush, A. J., Nunes, E. V., & Shoptaw, S. (2021). Bupropion and Naltrexone in Methamphetamine Use Disorder. N Engl J Med, 384(2), 140-153.
https://doi.org/10.1056/NEJMoa2020214
Samuels, E. A., Bernstein, S. L., Marshall, B. D. L., Krieger, M., Baird, J., & Mello, M. J. (2018). Peer navigation and take-home naloxone for opioid overdose emergency department patients: Preliminary patient outcomes. J Subst Abuse Treat, 94, 29-34. https://doi.org/10.1016/j.jsat.2018.07.013
Beaudoin, F. L., Jacka, B. P., Li, Y., Samuels, E. A., Hallowell, B. D., Peachey, A. M., Newman, R. A., Daly, M. M., Langdon, K. J., & Marshall, B. D. L. (2022). Effect of a Peer-Led Behavioral
Intervention for Emergency Department Patients at High Risk of Fatal Opioid Overdose: A Randomized Clinical Trial. JAMA Netw Open, 5(8), e2225582.
https://doi.org/10.1001/jamanetworkopen.2022.25582
References
Patel, E., Solomon, K., Saleem, H., Saloner, B., Pugh, T., Hulsey, E., & Leontsini, E. (2022). Implementation of buprenorphine initiation and warm handoff protocols in emergency departments: A qualitative study of Pennsylvania hospitals. J Subst Abuse Treat, 136, 108658. https://doi.org/10.1016/j.jsat.2021.108658
Ahmed, O. M., Mao, J. A., Holt, S. R., Hawk, K., D'Onofrio, G., Martel, S., & Melnick, E. R. (2019). A scalable, automated warm handoff from the emergency department to community sites offering continued medication for opioid use disorder: Lessons learned from the EMBED trial stakeholders. J Subst Abuse Treat, 102, 47-52. https://doi.org/10.1016/j.jsat.2019.05.006
SEMINAL STUDY
Opioid Use Disorder Treatment in the EMERGENCY DEPARTMENT
9.6
10.1 // Understanding Disparities in Rural Health
10.2 // Rural EM Clinical Practice
Up next: