A primary objective of early management of patients with opioid use disorder (OUD) following naloxone resuscitation from an opioid overdose is to prevent a second, potentially fatal overdose. This outcome depends on both medical stabilization and addressing multiple psychosocial factors. Current evidence favors initiation of buprenorphine/naloxone (BUP), but fewer than half of patients with OUD elect this option during an emergency department (ED) visit. Without BUP, ED management strategies such as brief intervention or referral to outpatient services are associated with less engagement in treatment at 30 days. Although many patients do leave our EDs with BUP and/or overdose education and naloxone (OEN) kits, there is currently no `safety net' for those who decline these resources. We propose a multi-disciplinary, multiple option program to these patients, as we hypothesize that assertive and structured support networks and intervention modalities may serve them more effectively than standard care. Our program integrates BUP with a unique outpatient collaboration between recovery coaches as defined by SAMHSA, and Yale's PRIDE paramedics, forming field teams (RCP) to comprehensively support patients with OUD following an overdose. The PRIDE program, centered in Yale Emergency Medicine, is an innovative collaboration between paramedics and home healthcare nurses who jointly facilitate access to community resources, reducing ED and Emergency Medical Service (EMS) use by seniors at risk of falls. With a total enrollment of over 5,600 seniors, we have demonstrated substantial decreases in ED and EMS utilization at 30 and 90 days. Adapting PRIDE to patients with OUD after a naloxone resuscitation, but refuse BUP initiation in the ED, RCP teams will perform an expanded brief negotiation interview (BNI) at home or a location of their choosing. An essential and novel aspect of our intervention is that the patient with OUD makes the choice of treatment modalities with assistance from the paramedic who can facilitate and help monitor BUP treatment, and the recovery coach who is trained in recognizing and accessing the community resources best suited to the patient. Besides BUP, which can be started whenever the patient accepts it, other community options include initiation of methadone, inpatient or intensive outpatient treatment, and mutual-support groups, all augmented by ongoing assistance by the RCP team. Based on extensive experience in our EDs, we anticipate enrolling 300 patients over 3 years. Of these, about half will receive BUP, and the other 50% will elect other modalities. Primary outcomes will be overdose events and engagement in treatment at 30 and 180 days. Secondary outcomes will be positive drug screens and self-reported opioid use. These outcomes will be compared to those of overdose survivors concurrently enrolled in an ED-initiated of BUP program, and historical controls, comprising patients with OUD who were not randomized to BUP in previous trials.
Patients with opioid use disorder (OUD) who are transported to the emergency department after an overdose are at risk for subsequent overdoses if their OUD is not treated. Although buprenorphine/naloxone (BUP) is currently considered the most effective treatment for OUD, fewer than half of patients agree to start it after an overdose. This study provides a model safety net for such patients, creating support teams comprising specially trained paramedics from Yale and Recovery Coaches from the Connecticut Community for Addiction Recovery who will improve access to BUP while assisting OUD patients with the many other psychosocial aspects of recovery, in order to decrease the risk subsequent overdoses.
