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Physicians: .25 AMA PRA Category I CreditsTM
Family Physicians: .25 Prescribed credits
Nurse Practitioners: .25 Contact hours

Release Date: May 6, 2015
Expiration Date: May 6, 2016

Estimated Completion Time: 15 minutes

There is no fee for this activity.

To Receive Credit

In order to receive your certificate of participation, you should read the information about this activity, including the disclosure statements, review the entire activity, take the post-test, and complete the evaluation form. You may then follow the directions to print your certificate of participation. To begin, click the CME icon above.

Program Overview

Learning Objectives

Upon successful completion of this educational program, the reader should be able to:

1. Discuss the significance of this article as it relates to your clinical practice.
2. Be able to apply this knowledge to your patient's diagnosis, treatment and management.

Faculty Information

Alan Ehrlich, MD
Assistant Professor in Family Medicine, University of Massachusetts Medical School, Worcester, Massachusetts, USA; Executive Deputy Editor, DynaMed, Ipswich, Massachusetts, USA

Michael Fleming, MD, FAAFP
Assistant Clinical Professor of Family Medicine and Comprehensive Care, LSU Health Science Center School of Medicine, Shreveport, Louisiana, USA; Assistant Clinical Professor of Family Medicine, Department of Family and Community Medicine, Tulane University Medical School, New Orleans, Louisiana, USA; Chief Medical Officer, Amedisys, Inc. & Antidote Education Company


Dr. Ehrlich, Dr. Fleming, DynaMed Editorial Team members, and the staff of Antidote Education Company have disclosed that they have no relevant financial relationships or conflicts of interest with commercial interests related directly or indirectly to this educational activity.

No commercial support has been received for this activity.

Accreditation Statements

ACCME: This activity has been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education through the joint providership of Antidote Education Company and EBSCO Publishing. Antidote is accredited by the ACCME to provide continuing medical education for physicians. Antidote Education Company designates this enduring activity for a maximum of 0.25 AMA PRA Category 1 CreditsTM. Physicians should only claim credit commensurate with the extent of their participation in the activity.

AAFP: This enduring material activity, DynaMed EBM Focus Volume 9, has been reviewed and is acceptable for up to 15.25 Prescribed credits by the American Academy of Family Physicians. AAFP certification begins March 5, 2014. Term of approval is for one year from this date. Each EBM Focus is approved for .25 Prescribed credits. Credit may be claimed for one year from the date of each update. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

AANP: This program is approved for 13.0 contact hour(s) of continuing education by the American Association of Nurse Practitioners. Program ID 1504207. This program was planned in accordance with AANP CE Standards and Policies and AANP Commercial Support Standards.

DynaMed Careers

The DynaMed editorial team is seeking specialist editors in the following fields: Gastroenterology, Nephrology, Oncology (especially Breast cancer and Pancreatic cancer), Ophthalmology, and Pediatric Neurology.

If interested, please send a recent copy of your CV to Rachel Brady at rbrady@ebsco.com.

DynaMed Contribution Opportunities

Become a DynaMed Resident Focus Reviewer
Education for Clinicians in Training

Last week 362 journal articles were evaluated via DynaMed's Systematic Literature Surveillance and summaries of 118 articles were added to DynaMed content.

Based on criteria for selecting "articles most likely to inform clinical practice," one article was selected by the DynaMed Editorial Team.

Emergency-Department Initiated Buprenorphine Treatment May Increase Addiction Treatment and Decrease Opioid Use in Patients with Opioid Dependence

Reference: JAMA 2015 Apr 28;313(16):1636 (level 2 [mid-level] evidence)

Prescription opioid and heroin dependence is a major public health problem, with an estimated 15.6 million problem opioid users worldwide (WHO 2009PDF). Illicit opioid use is associated with a number of comorbidities and complications that may require the user to seek care in the emergency department (ED), making the ED an important link between dependent users and potential treatment options. Referral to addiction treatment programs is the most common option available to physicians encountering patients with opioid dependence in the ED. Brief interventions in primary care or ED settings have shown promise at reducing alcohol misuse (Ann Emerg Med 2012 Aug;60(2):181, Cochrane Database Syst Rev 2008 Oct 8;(4):CD004148), but it is unknown if similar interventions would be helpful for initiating treatment in patients with opioid dependence. A recent randomized trial compared 3 interventions in 329 patients (mean age 31 years, 76% male) presenting to the ED with opioid dependence: treatment referral, brief intervention plus facilitated referral, and brief intervention plus ED initiated buprenorphine/naloxone treatment plus referral.

A 20-item health questionnaire was used to initially screen for opioid dependence in the past 30 days, followed by Mini-International Neuropsychiatric Interview and a urine sample of patients whose responses indicated non-medical opioid use in the past 30 days. Patients enrolled in formal addiction treatment programs were excluded, along with patients requiring hospitalization or requiring opioid medication for pain condition. Patients randomized to treatment referral received a handout about local addiction treatment services, while patients randomized to the brief intervention plus facilitated referral had a 10-15 minute interview followed by a treatment referral including a review of patient eligibility, insurance clearance, and transportation arrangement. Finally, all patients randomized to the brief intervention plus ED initiated buprenorphine/naloxone treatment received an interview followed by their first buprenorphine treatment in the ED if symptoms warranted, plus sufficient medication for home treatment until their follow-up appointment within 72 hours. This treatment group also received 10 weeks of buprenorphine treatment followed by a transfer for antagonist therapy maintenance or 2-week detoxification. The primary outcome was engagement in treatment, defined as patients enrolled and receiving formal addiction treatment on day 30 post-randomization.

The 30-day follow-up interview was completed by 74.2% of patients, but data on addiction treatment program enrollment at day 30 was available for 99% of patients and all patients were included in the primary outcome analysis. At day 30, patients receiving ED initiated buprenorphine treatment were significantly more likely to be engaged in treatment compared to patients receiving the brief intervention plus referral or a referral alone (78% vs. 45% vs. 37%, p < 0.001). Self-reported opioid use in past 7 days was also significantly lower with buprenorphine treatment, with mean number of days of use reported as 0.9 days with buprenorphine treatment vs. 2.4 days with the brief intervention plus referral vs. 2.3 days with referral alone (p < 0.001 across groups) and fewer patients in the buprenorphine group were receiving inpatient treatment. Of the 67% of patients providing urine samples, however, there were no significant differences in the rate of opioid negative urine toxicology between groups (57.6% with buprenorphine treatment vs. 42.9% with brief intervention plus referral vs. 53.8% with referral alone). There were also no significant differences between groups in HIV risk behaviors, outpatient addiction treatment visits, or the use of the ED for addiction treatment.

The results of this trial suggest that initiation of buprenorphine treatment in the emergency department with referral to a hospital-based primary care clinic may increase patient engagement in treatment and decrease self-reported opioid use within 30 days. This intervention was also associated with a reduction in the number of patients attending inpatient treatment programs, potentially reducing the cost of treatment. However, it is unknown if patients can be quickly and efficiently screened in busy emergency departments and if this treatment program can be replicated. Going beyond the usual ED referral and including a brief intervention along with a facilitated referral did not increase patient engagement or decrease opioid use compared to the standard referral alone, suggesting buprenorphine treatment may be the key to a successful intervention. In this trial, the buprenorphine was provided to patients at no cost and financial concerns, which may limit the use of ED-initiated buprenorphine treatment in other settings. Furthermore, physicians must undergo training before prescribing buprenorphine, which may inhibit some ED physician from participating in similar programs. It is also unknown whether this type of program could be successfully translated into the primary care setting, where physicians may also encounter patients with opioid dependence requiring treatment for addiction or other medical issues .

For more information, see the Opioid abuse or dependence topic in DynaMed.

Quick Access to Clinical Answers with the DynaMed App

DynaMed users can access valuable evidence-based content anywhere with the updated DynaMed mobile app. The app has been redesigned to make it easier and faster for physicians to find answers to clinical questions. The app features an improved user experience, seamless authentication, and easy access to the latest clinical content. It provides offline access and the ability to denote favorites, email topics, and write and save notes about particular topics. Users download the complete DynaMed content set and periodically receive notifications to update the content.

The DynaMed app is complimentary for all personal and institutional DynaMed subscriptions. The app has also been designed for easy one-time authentication via email, making the process as convenient as possible.

The app can be downloaded from the iTunes Store or Google Play. For more information, please visit the DynaMed Mobile Access page.

Critical Appraisal of the Medical Literature: A Simplified Approach

July 8 9, 2015 Portland State University - Portland, Oregon.

Join our Editorial Board members Sheri Strite and Michael Stuart and improve your critical appraisal skills. We aim to make critical appraisal of the medical literature meaningful, useful, simple, and doable. This program will be particularly helpful to those who routinely evaluate the medical literature.

Visit the Seminar page for more details.