Could a brief, ED-based counseling intervention curtail risky opioid use among patients who have a history of using the powerful painkillers for non-medical reasons? Investigators at the University of Michigan School of Medicine believe this may well be the case following a randomized clinical trial that tested the approach with 204 emergency patients who reported opioid misuse within the previous three months.
Half these patients were randomized to receive usual care as well as printed educational materials detailing how to prevent or respond to overdoses and listing local resources for treatment and suicide prevention. The other half received the printed educational materials as well as a 30-minute counseling session with a trained therapist who used motivational interviewing techniques to strengthen their desire to move away from risky opioid use behaviors. (See sidebar below: “Opioid-related Hospitalizations, Infections Up”)
Investigators followed up with all patients after six months, finding that those in the group that received the counseling intervention experienced a 40.5% reduction in behaviors that heighten the risk of an overdose on average, and they had a 50% average reduction in non-medical use of opioids. Patients who received printed materials but no counseling session experienced a 14.7% reduction in risky behaviors on average, and a 39.5% reduction in the non-medical use of opioids.1
Focus on Harm Reduction
Amy Bohnert, PhD, a co-author of the research and an assistant professor of psychiatry at the University of Michigan School of Medicine, explains that the researchers didn’t have to start from scratch when designing the intervention to reduce risky opioid behaviors.
“Our group had experience doing motivational interviewing interventions specifically for ED patients dealing with alcohol use and other drug use issues,” she explains.
Developers used the framework from these earlier interventions, which involves building a rapport with patients and getting to know their values, and repurposed it for the new intervention, with a few changes.
“A major shift in our thinking was that rather than focusing just on level of use, we had to spend some time thinking about this from a harm-reduction standpoint or reducing risky use, but not emphasizing so much on whether the use [of opioids] should continue at all,” she says. “We felt like that was really helpful in the participants being receptive to the intervention.”
Bohnert adds that the intervention fit in well with the full range of patients who present to the ED.
“The way we screened, we got people with injection heroin problems, and then on the other end of the spectrum we got people whose primary problem was chronic pain that was difficult to treat,” she says. “One of the neat things about this intervention, and one of the things I was excited about in designing it, is that it is not specific to one target population. “It has the potential to give therapists the tools to learn one intervention that could be helpful to a lot of different types of patients.”
Investigators note that motivational interviewing has been used effectively to help people reduce their use of alcohol and drugs as well as lose weight, but this is the first time the technique has been put to the test in a randomized clinical trial to see if it can reduce the risk of overdose.
The 30 minutes required to conduct the counseling sessions might be an issue for some EDs, Bohnert acknowledges. But she notes it did not present obstacles at the study site.
“It is not unusual for patients who are there for non-life-threatening problems to be [in the ED] for a couple of hours, so having a dedicated therapist who can work around the other needs of the treatment team was able to work pretty well,” she explains. “There were very few cases where we weren’t able to complete the whole session during the ED visit and had to finish it later.”
Bohnert says the counseling sessions would clearly not work as well if the burden of delivering them was on physicians.
“That wouldn’t work with the flow [of patients], but with the therapists, whose purpose is to deal with these more case management situations, it was feasible,” she explains.
However, investigators are working now on adaptations to the intervention to make it more feasible and cost efficient so that it could be applied in almost any emergency setting. For example, Bohnert notes that investigators have developed other drug and alcohol-related, brief motivational interventions that have been fully computerized.
“That is one option that would obviously have pretty broad potential for implementation in the ED,” she says.
The computerized option is under consideration, but the most immediate next step involves devising the intervention so that it can be delivered by interactive voice response (IVR) calls after patients leave the ED.
“There will be an artificial intelligence component that is going to optimize the frequency of contact,” Bohnert notes. “The real advantage of this approach — of identifying people while they are in the ED, and then delivering the intervention afterward — is that we can adapt the intervention to how much opiate medication the patients received as part of that ED visit.”
One option that will be available with the IVR approach is connecting patients with a live therapist if their perceived risk merits this level of interaction.
“It will be interesting to see how often that connection is really necessary,” Bohnert observes. “That will be a neat thing we will be able to learn because we are using artificial intelligence.”
One challenge for any intervention that targets patients at risk for opiate misuse is getting patients to disclose that they have actually used opiate medications for non-medical reasons. In the trial, more than 2,700 emergency patients between the ages of 18 and 60 were screened, and only those patients who disclosed that they engaged in opiate use for non-medical reasons were asked to fill out a questionnaire and agreed to participate in the study. Investigators say two-thirds of study participants had received a prescription for opiate medication within the past six months.
“In the case of this study, we have the benefit of the fact that we are collecting this data for research, and people are more willing to disclose in that situation,” Bohnert says. “We use the Current Opiate Misuse Measure (http://bit.ly/1VsExO4) to screen for opiate use, which has been specifically designed to not be as reactive to some of those issues of stigma with substance use, and better at picking up what might be called medical misuse or use that is beyond the prescribed level and possibly risky.”
Such validated instruments help clinicians identify appropriate patients for intervention, but Bohnert acknowledges the issue is an implementation challenge. Nevertheless, investigators are buoyed by the early results they have received thus far and are anxious to build on what they have learned.
“We really need the long-term health outcomes of the intervention, so we will continue to study this,” Bohnert notes.
Researchers will make their handbook and a therapist’s guide available on the University of Michigan Injury Center website: http://bit.ly/1zSvHOY.
REFERENCE
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Bohnert A, Bonar E, Cunningham R, et al. A pilot randomized clinical trial of an intervention to reduce overdose risk behaviors among emergency department patients at risk for prescription opioid overdose. Drug Alcohol Depend 2016;163:40-47.
SOURCE
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Amy Bohnert, PhD, MHS, Assistant Professor, Psychiatry, University of Michigan Medical School, Ann Arbor, MI. Email: [email protected].
