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ONLY THREE IN TEN PEOPLE WHO SURVIVE AN OVERDOSE RECEIVE MEDICATION TREATMENT
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The researchers identified 17,568 cases where an adult in Massachusetts survived an overdose between 2012 and 2014 . There was a 59% reduction in mortality for individuals taking methadone compared to those not taking medication, and a 38% reduction in mortality for those treated with buprenorphine. The was no change in morality associated with naltrexone. Despite these gains relative to morbidity, in the 12 months following the OD, only 34% of individuals received any medication for OUD: 11% received methadone maintenance treatment (median of 5 months); 17 received buprenorphine (median of 4 months); 6% received naltrexone (median of 1 month).

Treatment with opioid agonist therapy (methadone and buprenorphine) is associated with a reduction in all-cause and opioid-related mortality.  Only a minority of overdose survivors received treatment.   

Larochelle et al., Medication for Opioid Use Disorder After Nonfatal Opioid Overdose and Association With Mortality. Annals Of Internal Med, 2018.

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Frequently Asked Questions about ED-Initiated Buprenorphine

Frequently Asked Questions

Will patients flock to the ED if we start offering buprenorphine?

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.

Is this just replacing one drug for another?

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.

Should I worry about diversion?

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.

Do I need a DATA Waiver to administer buprenorphine in the ED?

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"

How long do I need to wait to initiate buprenorphine after a naloxone reversal for opioid overdose?

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.

Could you provide more details regarding management of pregnant patients who live with OUD?

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.

What is the worst thing that could happen after I administer buprenorphine?

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.

How many days of a buprenorphine prescription should I prescribe if I have a waiver?

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.

Can I write a prescription for 3 days without a waver?

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.

What are the different formulations of buprenorphine?

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.

Different protocols suggest dosing at different COWS scores, does it matter?

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.

Do I have to worry if a patient is also taking benzodiazepines?

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.

What mandatory/optional lab tests do you need for ED initiated 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.

How long must a patient be observed after receiving buprenorphine in the ED?

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.