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Reasonable Doubt

Reasonable Doubt

The Final Word on Buprenorphine

Start It in the ED

Runde, Dan MD

doi: 10.1097/01.EEM.0000657656.76830.f2
    buprenorphine, opioid misuse disorder

    You have an impossible job. Too many patients, too much acuity, and too little time, all crammed inside a system that is overloaded and ill-designed to meet the current demand. In spite of these challenges, tens of thousands of us will show up for the next shift, excuses be damned, and we will do what we can to care for each patient who comes through our doors.

    There's a specialist or primary care provider for almost every acute or chronic illness we see who might be better suited to care for a particular problem, but that doesn't stop us from caring for patients with asthma, diabetes, or a broken wrist. We're experts at MacGyvering excellence in the midst of execrable circumstances, which brings me to the point of this article: It's time for all of us to get off the sidelines and get on board with opioid agonist therapy.

    First, some clarifications: Opioid agonist therapy is also known as medication-assisted treatment (MAT) and medication for opioid use disorder (MOUD). I know it's annoying when things have multiple names and acronyms (looking at you, pseudotumor cerebri), but that's the way it is. For what it's worth, opioid agonist therapy is probably the preferred and least stigmatizing term, and it makes more sense than medication-assisted treatment. (I mean, isn't it medication-assisted treatment every time we prescribe an antibiotic or analgesic? Why the special distinction here?) Opioid agonist therapy technically includes full-agonist treatment (AKA methadone), but for now I'm going to focus on buprenorphine, for reasons that will become clear as you read along.

    Why Buprenorphine?

    Buprenorphine isn't a miracle medication, but it's pretty close for treating patients with opioid use disorder who are in withdrawal. First, it binds directly to the same receptor as the opioids that patients are using and from which they are withdrawing. Second, it's a partial agonist, which means that there's a ceiling effect for how much it can activate that mu receptor. This means there is built-in protection against over-sedation and respiratory depression, so this is a medication that comes with its own pharmacokinetic safety harness.

    Third, it has a higher affinity for that receptor than basically any other opioid, including fentanyl and heroin (diacetylmorphine), which makes buprenorphine protective if the patient decides to use a full agonist because it keeps the heroin, fentanyl, hydrocodone, etc., from getting to the brain and doing the dangerous things they do. Fourth, buprenorphine is long-acting, so most patients are able to function well on once-a-day dosing.

    But why prescribe buprenorphine? Maybe we agree that buprenorphine is a great medicine pharmacologically, but why do we need to bother treating ED patients with it? After all, opioid withdrawal isn't fatal. And isn't starting it complicated? Should we guarantee a patient has follow-up with the appropriate specialist before we give it?

    We treat patients dozens of times a shift regardless of whether we connect them with a specialist. We don't withhold aspirin from an ACS patient because we're not sure if we can get them cardiology follow-up or an albuterol inhaler from a patient with asthma because we don't know if there is a local pulmonology clinic. Ideally, we would be able to do a warm handoff to a specialist who cares for patients with opioid use disorder, but we don't live in an ideal world; we work in the ED and do the best with what's available. That applies to treating patients with buprenorphine.

    And starting a patient on buprenorphine is not difficult. We administer dozens of medications that are more finicky, have more potential for harm, and are much more difficult to titrate than buprenorphine. If you're smart enough to start a patient on pressors or propofol, you can initiate buprenorphine upside down and blindfolded.

    Opioid withdrawal might not be fatal, but that doesn't mean it's not acutely awful for patients. Our standard for treating pain has never been whether a condition might kill them, and it shouldn't be in this case. We have a safe medication that is nearly perfectly designed to treat this condition, and there's no non-stigma-based excuse not to be using it.

    High Fatality Rate

    I've got some bad news if potential mortality is still your bar for initiating treatment: When we turn away from these patients, they turn to self-treatment, and in the midst of the current fentanyl poisoning and contamination crisis, that self-treatment is all too often fatal. Patients presenting to the ED with a substance-related concern have a fatality rate six times higher than the general adult ED population. (Ann Emerg Med. 2020;75[1]:1; More specifically, 5.5 percent of patients treated in the ED for an opioid overdose are dead within a year, with the highest mortality rate coming within two days after ED discharge. (Ann Emerg Med. 2020;75[1]:13.)

    Those numbers are equal parts staggering and embarrassing, especially when you consider how few patients in this high-risk group are discharged with naloxone in hand or are offered opioid agonist therapy. Gail D'Onofrio, MD, a national leader and research pioneer in this area, makes an eloquent argument that the ED, rather than being a backstop, should be considered the front line and “an integral part of the response to the opioid crisis.” ( She's 100 percent correct. We can and must do better. One crucial step is that we must offer opioid agonist therapy to every patient who needs it, and we must start today.

    An important postscript: I realize you may have multiple questions and concerns about how to offer opioid agonist therapy in the ED, and I don't have the space here or the expertise to answer them all. Thankfully, I can point you to people who do. Dr. D'Onofrio and her colleagues offer a fantastic breakdown of common questions and objections about ED-based opioid agonist therapy in the New England Journal of Medicine. (2018;379[26]:2487.) Toxicologist Howard Greller, MD, of the Tox and the Hound blog has written an incredibly comprehensive and digestible discussion that is an absolute must-read for everyone in the ED. (

    The American Academy of Emergency Medicine also issued a white paper on ED-based management of opioid use disorder that might be the current definitive word on the topic, and can address with receipts any lingering concerns you might have. (

    Dr. Rundeis the assistant residency director and an assistant professor of emergency medicine at the University of Iowa Hospitals and Clinics, where he serves as a co-director for the associate fellowship in medical education. He creates content for and is a member of the editorial board, and is a content contributor for Follow him on Twitter @Runde_MC, and read his past articles at

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