Other Resources & FAQ's

EDs that have ED-initiated buprenorphine protocols have not noted this to happen. In fact the patients with OUD are already in the ED whether presenting with life-threatening illness such as overdose or less urgent, such as skin infections or withdrawal.

No. Buprenorphine is a medication, prescribed by physicians and taken under supervision. Treatment with buprenorphine and methadone, both opioid agonists, is effective in reducing withdrawal symptoms, cravings, HIV transmission and other infectious diseases, interactions with the judicial system, as well as improving social relationships and becoming functional members of society.

Do you worry about diversion of every opioid you prescribe? In truth diversion of buprenorphine is less than other opioids. When individuals are obtaining buprenorphine off the street they are almost always trying to reduce withdrawal. Every time there is one less use of injection drugs there is one less opportunity for overdose and death.

No, buprenorphine may be dispensed by a non-waivered practitioner for up to 72-hours. "The 72-hour rule" (Title 21, Code of Federal Regulations, part 1306.07(b) allows physicians to administer narcotic drugs for the purpose of reliving acute withdrawal symptoms when necessary while arrangements are being made for referral to treatment"

In general, the recommendation is to wait 2 hours after a naloxone reversal to perform the COWS and treat accordingly. Remember to always ask about methadone and if the individual has methadone on board, waiting longer is more prudent.

All women of child bearing age should have a urine pregnancy sent for long term management. Theoretically one would prescribe buprenorphine alone (Subutex) without naloxone to prevent withdrawal. However, in the ED with observed induction any formulation can be used.

Not recognizing that (1) the patient has other opioids on board that will be displaced from the receptors by buprenorphine and you can precipitate withdrawal; (2) the patient was experimenting with an opioid and does not have a moderate to severe opioid use disorder, and may develop overdose symptoms.

The goal is to develop agreements with community providers and opioid treatment programs so that you would only need about 3 days. However, in some communities, access may be difficult and you may need to extend this up to 7 days.

No, the patient may come back to the ED for two subsequent days and you can administer a dose for up to three days in total. You cannot prescribe buprenorphine without a MAT waiver.

The most common is Suboxone which is a combination of buprenorphine/naloxone 0.5mg. This preparation comes in SL tablets (generic) or film dissolved under the tongue. There are different brand names including Subzolv tablets and Bunavail film preparations. Buprenorphine alone is available as SL tablet (Subutex) without the naloxone that is often used in pregnancy to decrease risk of withdrawal symptoms.

The first principle related to dosing buprenorphine for moderate to severe opioid use disorder (OUD) is that the patient is in withdrawal. Since buprenorphine has a high affinity to the mu receptor it will displace any other opioid on the receptor and can therefore precipitate withdrawal. Therefore, the most important principle is that the patient is in withdrawal. A careful history regarding last use is important. In general patients are in withdrawal 12 hours after last heroin use and 24 hours after oxycodone. For methadone, A long acting opioid, one should wait 48-72 hours. Knowing this, variations in COWS can exist, one needs to understand pharmacology. For example, if an individual is 12 hours out of last use of heroin and his COWS is 8, then one can initiate a dose of buprenorphine. With the use of methadone one should wait until more moderate withdrawal such as a COWS of 13-15.

Many patients will be taking benzodiazepines and other substances along with their opioids and this is not a reason to withhold treatment. If co-use is suspected you should counsel the patient regarding the higher risk of overdose when using benzodiazepines, alcohol or other sedatives with buprenorphine.

There are no mandatory tests needed if you are sure that the patient has OUD. A pregnancy test is helpful in terms of referral and deciding on whether to administer or prescribe buprenorphine with or without naloxone. If there is concern regarding methadone use you may check a urine sample, but methadone can be in the urine for longer periods of time. Buprenorphine is metabolized in the liver and may be a problem if the LFTs are greater than 5 times normal. However, obtaining LFTs is not essential in the first visit but may be helpful for the receiving referral site. Other tests such as hepatitis C and HIV can be done at the referral site.

You will notice a major improvement after 20 to 30 minutes. The ED visit that includes assessment of OUD, administering buprenorphine, counseling regarding overdose, buprenorphine treatment and providing a specific referral can be accomplished within 60-90 minutes, which is in guidelines for an urgent visit.