Comparing Interventions for Opioid Dependent Patients Presenting in Medical Emergency Departments

As addiction treatment becomes increasingly integrated into the medical care system, two
models have rightly received a great deal of attention. The first is the use of Screening,
Brief Intervention, and Referral to Treatment (SBIRT) models to identify cases, provide
therapeutic contact, and refer the more severe cases to longer-term care. The second is the
treatment of addictions using medical models of treatment, including those that can be
implemented in primary care settings. Much less attention has been paid to optimizing
strategies for bridging the gap between SBIRT and more intensive/longer-term treatment for
those on the severe end of the spectrum. This factor is of critical importance for opioid
dependent patients, whose needs are not met by brief interventions or brief treatment.
Emergency room interventions for substance use disorders have been largely limited to brief
interventions/SBIRT models, and these have focused primarily on alcohol. Although there is a
substantial literature documenting the value of case management in linking drug users to
treatment, this approach has not been applied to drug users in the emergency department (ED)
setting.

In a sample of opioid dependent patients seen in a medical ED who are not currently engaged
in treatment, this study will compare the effects of brief strengths-based case management
(SBCM) to the effects of screening, assessment and referral alone. Participants meeting
DSM-IV criteria for opioid dependence will be randomly assigned (150 per group) to receive 1)
Screening, Assessment and Referral or 2) up to 6 sessions of SBCM based on the model
previously implemented by Rapp and colleagues in prior studies. Staff who are blinded to
treatment condition will complete follow-up assessments at 3 and 6 months. Aims of the study
are to identify the main effects of SBCM on substance abuse treatment initiation and
engagement, use of opioids and other drugs, and broader measures of health and life
functioning; to examine the interactions between treatment assignment and selected
participant attributes in predicting treatment initiation, engagement, and substance use
outcomes; and to examine effects of treatment involvement on substance use outcomes in the
two treatment groups.

The proposed study will be the first trial using a case management approach to link drug
dependent patients presenting in EDs to longer-term addiction treatment. It will be one of
the first trials focusing specifically on opioid dependent patients in medical EDs. A further
innovative feature is that the case management approach will emphasize linkage to
pharmacotherapy, facilitating linkage to office-based buprenorphine, methadone, or naltrexone
for patients who desire this treatment.

Inclusion Criteria:

1. Registration as patient in the ED during study screening hours;

2. Endorsement of three or more opioid dependence criteria on the DSM-IV checklist

3. Age 18 years or older;

4. Adequate English proficiency;

5. Ability to provide informed consent;

6. Self-report use of opioids in the last 30 days

Exclusion Criteria:

1. Inability to participate due to emergency treatment;

2. Significant impairment of cognition or judgment rendering the person incapable of
informed consent. (e.g., traumatic brain injury, delirium, intoxication);

3. Status as a prisoner or in police custody at the time of treatment;

4. Current engagement in substance use disorder treatment;

5. Residence more than 50 miles from the location of follow-up visits;

6. Inability to provide sufficient contact information (must provide at least 2 reliable
locators);

7. Unavailable for follow-up (e.g., planning to relocate within 6 months)

8. Prior participation in the current study.

9. Current participation in a research study related to substance use.