Elsevier

Drug and Alcohol Dependence

Volume 163, 1 June 2016, Pages 40-47
Drug and Alcohol Dependence

Full length article
A pilot randomized clinical trial of an intervention to reduce overdose risk behaviors among emergency department patients at risk for prescription opioid overdose

https://doi.org/10.1016/j.drugalcdep.2016.03.018Get rights and content

Highlights

  • This trial included emergency department patients with risky opioid medication use.

  • The intervention used a motivational interviewing framework and a computer aid.

  • The intervention reduced overdose risk behaviors more than enhanced usual care.

  • The approach is feasible and potentially effective for promoting safer opioid use.

Abstract

Background and aims

Prescription opioid overdose is a significant public health problem. Interventions to prevent overdose risk behaviors among high-risk patients are lacking. This study examined the impact of a motivational intervention to reduce opioid misuse and overdose risk behaviors.

Methods

This study was a pilot randomized controlled trial set in a single emergency department (ED) in which, 204 adult, English-speaking patients seeking care who reported prescription opioid misuse during the prior 3 months were recruited. Patients were randomized to either the intervention, a 30-minute motivational interviewing-based session delivered by a therapist plus educational enhanced usual care (EUC), or EUC alone. Participants completed self-reported surveys at baseline and 6 months post-baseline (87% retention rate) to measure the primary outcomes of overdose risk behaviors and the secondary outcome of non-medical opioid use.

Findings

Participants in the intervention condition reported significantly lower levels of overdose risk behaviors (incidence rate ratio [IRR] = 0.72, 95% CI: 0.59–0.87; 40.5% reduction in mean vs. 14.7%) and lower levels of non-medical opioid use (IRR = 0.81, 95% CI: 0.70–0.92; 50.0% reduction in mean vs. 39.5%) at follow-up compared to the EUC condition.

Conclusions

This study represents the first clinical trial of a behavioral intervention to reduce overdose risk. Results indicate that this single motivational enhancement session reduced prescription opioid overdose risk behaviors, including opioid misuse, among adult patients in the ED.

Introduction

Starting in the 1990s, opioids were increasingly prescribed to treat pain in the U.S., particularly for chronic non-cancer pain (Paulozzi et al., 2011). An unintended consequence of these efforts to reduce pain-related suffering has been an alarming increase in opioid-related addiction and overdoses (Compton and Volkow, 2006, Office of National Drug Control Policy, 2011). Specifically, the rate of prescription opioid overdose deaths in the U.S. increased 293% between 1999 and 2009 (Calcaterra et al., 2013), and opioid-related emergency department (ED) visits nearly tripled from 2004 to 2011 (Substance Abuse and Mental Health Services Administration (SAMHSA), 2013). Additionally, the non-medical use of prescription opioids (NMUPO) is a problem associated with opioid prescribing that has an important role in overdose risk, with NMUPO commonly found in investigations of opioid overdose fatalities (Hall et al., 2008).

Non-fatal overdose is more common than fatal overdose, with an estimated 23 non-fatal overdoses for every fatality (Centers for Disease Control and Prevention (CDC), 2014). Non-fatal prescription opioid overdose is associated with substantial morbidity, such as pulmonary impairment and neurological damage from prolonged hypoxia (Warner-Smith et al., 2001). People who have experienced a non-fatal overdose are at heightened risk for future overdose (Coffin et al., 2007). In addition to NMUPO, a number of specific behaviors have been found to increase risk, such as combining different substances, injecting, using alone, and consuming more than usual amounts of a given substance (Coffin et al., 2007, Cone et al., 2004, Gutierrez-Cebollada et al., 1994, Park et al., 2015, Paulozzi et al., 2012, Strang et al., 2008). Reducing these behaviors is an important target of overdose prevention interventions.

The ED is a critical setting to address the public health problem of prescription opioid overdose. In 2010, an estimated 51% of ED visits by adults nationally were for a painful condition, and 31% of all ED visits resulted in an opioid being prescribed. ED physicians write a substantial proportion of opioid prescriptions, particularly to those under age 40 (Cantrill et al., 2012). ED patients are also more likely to be engaged in risky substance use than the general community (Cherpitel, 2003, Cunningham et al., 2003). Thus, clinical encounters in the ED could provide an opportunity to intervene with patients who are at increased risk for opioid overdose. To date, there have been no published ED-based trials to address overdose risk.

To address this gap, we developed a 30-minute, therapist-delivered and tailored intervention for the ED setting. The intervention was primarily informed by motivational interviewing (MI) strategies (Miller and Rollnick, 2013, Miller and Rose, 2009) due to the demonstrated utility of MI in promoting changes in health-related behaviors, including substance use (Miller and Rollnick, 2013). We conducted a pilot randomized controlled trial that compared the intervention to enhanced usual care (EUC) only. The present study tests the hypothesis that the motivational intervention results in reduced self-reported overdose risk behaviors during the six months following randomization compared to EUC alone.

Section snippets

Setting

Recruitment occurred in the ED at the University of Michigan Medical Center (UMMC) between April, 2013 and March, 2014. Standard care for opioid safety in this ED is that all patients leaving with opioids or a prescription receive instructions to not operate machinery and avoid alcohol use. The study received approval from the institutional review board at the University of Michigan.

Recruitment and participants

Fig. 1 displays the flow of participants through the study. Research staff approached patients aged 18–60 while

Results

In total, 2,250 ED patients completed the screening survey (see Fig. 1). Of the 204 participants in the trial, 178 (87%) completed the six month assessment. Six participants randomized to the intervention did not receive the assigned protocols; of those 6, 5 (83%) completed the six month follow-up. Participants with a prior history of overdose who were randomized to EUC only were more likely to be lost to follow-up (24%) compared to all other study groups (all 8% or less).

Table 2 reports the

Discussion

The present study is the first trial of a motivational intervention focused on reducing opioid overdose risk behaviors among those with a prior non-fatal opioid overdose and/or who misuse prescription opioids. Analyses indicated that the intervention reduced self-reported behavioral outcomes compared to a control condition. These findings suggest this is a promising strategy for reducing overdose morbidity and mortality.

Self-reported behavioral intentions and knowledge about overdose risk

Conclusions

This study provides the first examination of a motivational intervention for reducing prescription opioid overdose risk. This study established the feasibility of this therapist-delivered brief intervention to ED patients and provided evidence of intervention effects on self-reported overdose risk behavior. Although the study has several important limitations, the findings indicate this intervention is a promising strategy to reduce the public health epidemic of opioid overdose, thus warranting

Contributors

Authors Amy Bohnert (study principal investigator), Maureen Walton, Rebecca Cunningham, Mark Greenwald and Frederic Blow conceptualized the study design and were primarily responsible for the conduct of the trial. Authors Stephen Chermack and Erin Bonar provided clinical training and supervision to therapists during the trial. Author Laura Thomas provided project management. Amy Bohnert took primary responsibility for data analysis and for writing and revising all drafts. All other authors

Conflicts of interest

No conflict declared.

Role of funding

Source: This project was supported by the Centers for Disease Control and Prevention (CDC) grant R49CE002099. The funding source had no role in the design of the study or the reporting of the study.

ClinicalTrials.gov identifier

Safety & Prevention Outcomes Study (SPOS); NCT01894087 (Registered July 2, 2013, prior to the end of data collection).

Acknowledgements

The authors wish to thank Anna Eisenberg, Mary Jannausch, Lynn Massey, Phillip Nulph, and Lisa Zbizek-Nulph for their contributions to this study.

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