emergency department

In a PEER umbrella systematic review of systematic reviews, a meta-analysis on three RCT found that:

• Retention in treatment improves when OUD is treated in primary care (86% vs 67% in specialty care, risk ratio [RR] of 1.25, 95% CI 1.07 to 1.47) 
• Street opioid abstinence was also higher in primary care settings (53% vs 35%, RR = 1.50, 95% CI 1.12 to 2.01, I2 = 74%). However, heterogeneity was high and this included both self-reported and urine-confirmed data.

There is reasonable evidence that patients with OUD should be managed in the primary care setting.

Buprenorphine initiation in emergency departments was found in a narrative systematic review (Kaczorowski et al., 2020) to have:

• positive short-term effects on treatment outcomes (i.e. retention and use)

The review concluded that while EDs seems to be an appropriate setting for initiating opioid agonist treatment, in order to be sustained, it likely needs to be coupled with community-based follow-up and support to ensure longer-term retention.

Naloxone is recommended in an evidence-based guidance (Neptune, 2018) to be used in case of suspected synthetic opioids, both in community and hospital settings.

Specificities with regard to fentanyls in comparison to heroin overdoses are the followings:

• a more rapid administration of naloxone is warranted because of the rapid onset of fentanyls,
• a more rapid escalation of additional doses for naloxone may be needed in comparison with heroin or other opioids,
• overall, higher doses of naloxone may be needed for fentanyl patients in comparison with heroin patients,
• Fentanyl patients may require a longer period of observation in hospital than heroin patients.

Brief interventions in emergency settings were found in a systematic review without meta-analysis (EMCDDA, 2016, 16 studies, N=8 875) to have no effect in:

• significantly decreasing substance use (mainly alcohol) and related harms 

The same results were confirmed in a more recent narrative systematic review (Kaczorowski et al., 2020, 12 studies) that focused specifically on ER-initiated interventions for opioid users.

A systematic review (Wilson et al 2019) found no evidence to support an association between prescription monitoring programmes (PMPs) and:

• reduced opioid prescribing and dispensing;
• reduced non-medical prescription opioid use.

There were limited but inconsistent evidence supporting an association between PMPs and reduced Scedule II opioid prescribing and dispensing and reduced multiple provider use. Further studies are needed to determine the effectiveness of PMPs.

A systematic review without meta-analysis (Lin et al 2019, 13 studies) found no evidence of effect of telemedicine-delivered treatment (psychotherapy or pharmacotherapy) interventions for substance use disorders.

Studies examined suggest this type of intervention is an effective alternative, particularly where face-to-face treatment is less available, but more research is needed on their effectiveness.

A systematic review without meta-analysis  (Vold et al 2019, 7 RCT and 3 cohort studies, high risk of bias), found uncertain results on the effects of integrated care models on the treatment of infectious diseases in people with substance use disorders.

A systematic review without meta-analysis (Penzenstadler et al 2019, 5 datasets) found no clear superiority of results of assertive community treatment (ACT) in reducing substance use (compared to control group).

ACT originally developed for patients with severe mental illness, providing personalized, high intensity, holistic and integrated multidisciplinary community care services.