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Start Buprenorphine for Opioid Addiction in the ED

Sorelle, Ruth MPH

doi: 10.1097/01.EEM.0000586428.14838.c3

Treatment with buprenorphine for opioid addiction should begin in the emergency department where overdose patients often arrive first, according to two experts who have studied the issue.

“One in 20 overdose patients who survives and is discharged from the emergency department dies within a year,” said Scott G. Weiner, MD, MPH, the chief of health policy and public health in the department of emergency medicine at Brigham and Women's Hospital in Boston. “These were fairly young people.”

Dr. Weiner and his colleagues used three Massachusetts data sets (a master demographics list, an acute care hospital case-mix database, and death records) to study one-year outcomes of patients discharged from the emergency department with opioid overdose. A total of 635 (5.5%) of the 11,557 patients who met study criteria died within a year, 130 (1.1%) died within a month, and 29 (0.25%) died within two days. (Ann Emerg Med. 2019 Jun 19. doi: 10.1016/j.annemergmed.2019.04.020; in press.)

Getting the message across to patients and physicians is important, Dr. Weiner said. “You can use this with patients, telling them, ‘You have a one in 20 chance of being dead in a year.’ Then maybe you can connect them to buprenorphine and get them to the services they need.” He said the response should be similar to the one for STEMI patients—call in the whole team. “For many years, we didn't have options. We felt helpless,” Dr. Weiner said.

He said Gale D'Onofrio, MD, the chair of emergency medicine at Yale Medical School in New Haven, CT, started to change attitudes when she began treating overdose patients with buprenorphine in the ED. Naloxone should still be the first response to an overdose, but buprenorphine should come second as a long-term treatment.

Dr. D'Onofrio and her colleagues ran a study to determine outcomes when patients receive buprenorphine in a primary care setting. One group of patients received referral to treatment resources, a second received a brief intervention with referral that included insurance clearance and arranging for transportation to a treatment site, and the third received buprenorphine in the ED that continued for 10 weeks with primary care. (J Gen Intern Med. 2017;32[6]660;

That study found that the ED-initiated buprenorphine treatment was associated with improved retention in addiction treatment and reduced illicit opioid use after two months of buprenorphine in the primary care setting. At two months, 68 of 92 patients (74%) were receiving addiction treatment in the buprenorphine compared with 42 of 79 (53%) in the referral group and 39 of 83 (47%) in the brief intervention group. Results at six and 12 months, however, did not differ significantly.

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Increasing Retention

“We have warm handoffs to providers or opioid treatment programs in the community,” said Dr. D'Onofrio. “In New Haven, we have great sites with which we have partnerships and specific times we send patients who we have initiated on buprenorphine.”

Asked about the mixed results of her trial, she said no time is defined for when patients should discontinue buprenorphine. “Many people are on agonist treatment for years,” she said. “Our study was funded by the National Institute for Drug Abuse for two months, supplying medication. After that, we transitioned patients to other providers based on their preference. Unfortunately, individuals often stop agonist treatment after six months. We are trying to learn ways to increase retention as often this results in a return to [opioid] use.”

The strategies that Drs. Weiner and D'Onofrio recommend require a different attitude toward those who survive an overdose. Previously they were observed until they were ready to leave, Dr. Weiner said. Some just walked out of the emergency department when they could.

“Before, we would just give them a list of detox facilities, knowing full well that maybe their insurance wouldn't be taken there or there wouldn't be beds available,” he added. “Patients were going out and using again.”

Giving buprenorphine in the emergency department changed that, Dr. Weiner said, adding that it was amazing to see the difference, especially when combined with his hospital's active bridge clinic that prescribes buprenorphine. “There is increased retention in the treatment clinic,” he said. “When we start them on treatment, it takes away the fear of withdrawal. Once that happens, they can talk about the next steps.”

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Waiver Training

But barriers remain. Physicians are required to have eight hours of training to receive a treatment waiver, and nurse practitioners and other midlevel practitioners need 24 hours. That can prevent many doctors from signing up as can the feeling that treating addiction is not their role, Dr. Weiner said.

Yet Drs. Weiner and D'Onofrio said initiating treatment in the ED can start an overdose patient on the road to treatment. Irene Berita Murimi, PhD, an assistant professor at the Massachusetts College of Pharmacy and Health Sciences, wrote in a commentary accompanying Dr. D'Onofrio's study that the two-month results showed that patients offered continued treatment were more likely to use it. (J Gen Intern Med. 2017;32[6]:683;

“This finding suggests the need for concerted efforts by clinicians, payers, and policymakers alike to address not only the barriers to buprenorphine therapy initiations, but also the challenges that limits its continued use,” she wrote.

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Ms. SoRellehas been a medical and science writer for more than 40 years, previously at the University of Texas MD Anderson Cancer Center, the Houston Chronicle, and Baylor College of Medicine. She has received more than 60 awards, including the Texas Human Rights Foundation Award. She has been a contributor to EMN for more than 20 years.

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