Building on a 2015 study, researchers at the Yale schools of Medicine and Public Health have demonstrated the cost-effectiveness of buprenorphine as an emergency department treatment for individuals with opioid use disorder.

The study analyzed the cost-effectiveness of three treatments for individuals screening positive for opioid addiction: referral alone, brief counseling intervention with facilitated referral and ED-initiated buprenorphine. ED-initiated buprenorphine was the most cost-effective with an average cost of $1,752, compared with $1,805 for brief intervention and $1,977 for referral only. Led by Yale School of Public Health professor Susan Busch and medical school professor Gail D’Onofrio, the study was published in the journal Addiction in August 2017. Buprenorphine — a molecule that blocks the brain’s opioid receptors — relieves opioid withdrawal symptoms and helps prevent relapse.

“Our study is one more piece of evidence that we should be considering ED-initiated buprenorphine when we see opioid use disorder,” said Kathryn Hawk, a medical school instructor and co-author of the study. “The previous study showed improved outcomes, increased treatment engagement and decreased days of opioid use. The fact that we’ve also been able to show cost-effectiveness is just one more reason why health systems and emergency departments should look at implementing the treatment.”

This 2015 study, published in the Journal of the American Medical Association, showed that patients who were given a brief counseling intervention and a dose of buprenorphine were twice as likely to be engaged in formal treatment and less likely to use illicit opioids 30 days after receiving the treatment.

The researchers then analyzed the cost-effectiveness of the three treatments, noting that demonstrating cost-effectiveness of the drug would be an essential way to increase its appeal.

“In the era of managed health care, whether a treatment works is only one component in whether or not it gets implemented across health systems,” Hawk said.

Steven Bernstein, a professor at the medical school and Yale School of Public Health and co-author of the study, noted that this is of particular importance when studying substance use, as health care systems have historically not paid enough attention to or offered a broad range of services to these patients.

The researchers looked at health care-associated costs across the three treatment methods, including the costs of emergency department care, addiction treatments costs, inpatient and outpatient costs and medication costs. According to Hawk, they analyzed these costs through the Treatment Services Review — a survey of medication used by patients of substance abuse.

The patients in the study included 329 opioid-dependent individuals who came into the Yale New Haven Hospital emergency department between April 2009 and June 2013, according to the paper.

Their findings — which indicated highest engagement in treatment and lowest opioid use after 30 days in the buprenorphine patient group — suggest the widespread implementation of this treatment strategy in EDs, Bernstein said.

However, most EDs do not currently provide any of these three treatments for opioid patients and will, at best, provide a referral to outside treatment centers, Bernstein said. He noted that only a small number of EDs, including Yale’s, will prescribe buprenorphine for addiction treatment.

“Historically, prescription of this medicine has been outside of the scope of emergency medicine,” Bernstein said. He added that physicians are required to undergo a special training by the Drug Enforcement Administration to receive the credential to prescribe buprenorphine.

Still, as a result of the first study, Hawk noted an increased interest in ED-initiated buprenorphine nationwide.

She added that the Connecticut Opioid Response Initiative is one of many organizations across the country working to increase the number of buprenorphine prescribers in the state.

Hawk said that one of the researchers’ next steps may include facilitating the implementation of ED-initiated buprenorphine in rural sites, which may have different accesses to resources in their communities.

“The real importance of the work is that it can help physicians and health systems overcome the barriers of ED-initiated buprenorphine by getting the necessary training and setting up those relationships between emergency departments and community treatment providers,” Hawk said. Health providers must recognize that implementing the prescription of buprenorphine doesn’t end in the emergency department, as primary care providers and internal medicine physicians must continue the treatment for these patients, according to Bernstein.

More than 33,000 people died from opioid overdose in the U.S. in 2015, according to the Centers for Disease Control and Prevention.

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