Prescribing Buprenorphine for Opioid Use Disorders in the ED: A Review of Best Practices, Barriers, and Future Directions

Figures & data

Figure 1 Study selection process.

Table 1 Quality Assessment of Included Studies

Author	Random Assignment		Allocation Concealment		Blinding of Participants		Blind Evaluation for Outcomes			Incomplete Outcome Data		Selective Reporting		Other Bias
Quality Assessment of Included Randomized Controlled Trials
D’Onofrio et al 2015^Citation13	Low		High		High		High			Low		Low		n/a
Srivastava et al 2019^Citation21	Low		High		High		Unclear			Low		Low		n/a
Author	Selection							Outcome
	How Representative	Selection of Nonexposed Cohort		Ascertainment of Exposure		Demonstration of Novel Outcome		Comparability Basis of Design and Analysis (Max. 2)	Assessment of Outcome		Follow-Up Long Enough		Adequacy of Follow-Up		Total Score (Max 9)
Newcastle-Ottawa Scale for Assessing the Quality of Included Cohort Studies
Berg et al 2007^Citation42	✓			✓		✓			✓						4/9
Dunkley et al 2019^Citation19	✓			✓		✓			✓		✓				5/9
Kaucher et al 2019^Citation20	✓			✓		✓		✓	✓		✓		✓		7/9
Kelly et al 2019^Citation29	✓			✓		✓			✓		✓				5/9
Kawasaki et al 2019^Citation41	✓			✓		✓			✓		✓		✓		6/9
Bogan et al 2020^Citation22	✓			✓		✓			✓		✓		✓		6/9
Carroll et al 2020^Citation35	✓			✓		✓		✓	✓						5/9

Notes: ✓ = presence of specific rating criteria; comparability basis is rated 0–2, while other columns are rated 0–1.

Table 2 Published Protocols for Emergency Department Buprenorphine Induction

Author	Method	Clinical Assessment and Induction Threshold	Dosing	Plan for Follow-Up	Outcomes
Berg et al 2007^Citation42	Retrospective cohort study of 158 patients investigating adverse outcomes of buprenorphine when treating patients with OUD in the ED	SOWS OOWS	Initial: 0.3mg – 0.9mg IM Maximum: Not specified	Patients were given IM doses of buprenorphine after being evaluated with either SOWS or OOWS to assess for withdrawal symptoms The buprenorphine group was compared to a symptom management group and a group that did not receive pharmacological intervention	8% (7/88) of patients who were treated with buprenorphine had a drug-related return to the ED within 30 days compared with 17% (5/29) of patients who received only symptomatic treatment
D’Onofrio et al 2015^Citation13	RCT of 329 patients using three different treatments arms to assess patient retention in MAT after ED treatment	Presences of DSM-IV OUD by MINI COWS to determined moderate/severe withdrawal If no symptoms, consider unobserved induction	Initial: 8 mg on day one Follow up: 16 mg on days two and three	Scheduled appointment with hospital primary care within 72 hours Prescribed 16 mg on day two and three until appointment	78% (89/114) of patients induced with buprenorphine in the ED were still in addiction treatment at 30-day mark when compared to 37% (38/102) in the referral only group
Duber et al 2018^Citation32	Clinical review summarizing strategies for identifying, treating, and transitioning patients with OUD	COWS Induction threshold not specified	Initial: 2–4 mg (but can start at 8 mg) Second: 2–4 mg if symptoms persist Max: 8–12 mg (increase if heavy user)	Recommend SOAPP-R or NIDA-m-ASSiST for screening of OUD in the ED Follow up appoints should happen ASAP within 72 hours There needs to be a robust bridge between ED and MAT Warm hand-offs utilizing social workers	N/A
Dunkley et al 2019^Citation19	Retrospective cohort study of 18 patients with OUD investigating the feasibility of using buprenorphine in an ED CDU setting and retention of patients in MAT programs	Presence of DSM-5 OUD determined by toxicology fellow COWS score ≥ 10	Initial: 2–0.5 mg of buprenorphine-naloxone Max: 8:2 mg maximum dose	Discharge at 24 hours with follow up appointment in the MAT clinic MAT clinic with same provider who initiated buprenorphine in the ED-CDU	63% (n = 12/19) of patients induced in ED attend initial MAT visit. 47% (9/19) still active at 1 month, and 21% (4/9) still active at 6 months.
Kaucher et al 2019^Citation20	Retrospective study of 219 patients with OUD investigating the retention of patients in MAT programs after induction of buprenorphine in the ED	COWS 6–12 COWS ≥ 13	Initial COWS 6–12: 2–4 mg Initial COWS ≥ 13: 4–6 mg Max: 16 mg	Next day MAT follow up with intranasal naloxone and SBIRT resources If X-waivered: prescribe up to buprenorphine/naloxone 16 mg if next day appointment cannot be made	At the 30-day mark, 49.3% (108/219) of patients induced with buprenorphine were retained in MAT programs.
Srivastava et al 2019^Citation21	RCT of 26 patients investigating effectiveness of buprenorphine vs clonidine in retaining patients in MAT program	Presence of opioid withdrawal Optional COWS	Initial: Not specified Maximum: 12 mg	5-day supply of buprenorphine (8 mg/day) dispensed at one time in 8 mg tablets Map given to patients showing nearest pharmacy open 7 days a week Printed information and map with location of addiction facility	Patients induced with buprenorphine in the ED were more likely to receive opioid agonist treatment at 1-month mark when compared to clonidine, 62% (8/13) vs 8% (1/13), respectively.
Reuter et al 2019^Citation23	Scientific abstract detailing a prospective study of 212 patients with OUD who were treated with buprenorphine in the ED and followed into MAT programs	COWS Induction threshold not specified	Initial: 4 mg Second: 4 mg dose if COWS > 8	Patients discharged to “close opioid treatment provider” for next day follow up Patient can come back to ED for buprenorphine treatment on weekends and holidays	Included 89 patients, only 71 actually began MAT. 83% (59/71) of patients went to first follow up appointment, and of those 59, 95% (56/59) were still in program at 6 months
Melnick et al 2019^Citation27	Planned randomized trial to be carried out in 20 ED across 5 healthcare systems	Presence of DSM-5 OUD COWS ≥ 8 COWS < 8 consider unobserved induction and referral	Initial COWS 8–12: 4 mg Initial COWS ≥ 13: Consider 8 mg Max: Not specified	If X-waivered: physician prescribes 16 mg of buprenorphine for each day until appointment with outside addiction treatment If not X-waivered: consider instructing patient to return to ED for 2 days of 16 mg of buprenorphine dosing with referral for addiction treatment Warm handoff to outside addictions provider within 24–72 hours	Not yet published
Cisewski et al 2019^Citation31	Narrative review that discusses the approach to initiating buprenorphine use in the ED for opioid-abuse recovery	COWS > 7	Initial: 4mg Max: 16 mg	Provide patient with MAT clinic information within 48–72 hours If X-waivered: prescribe 3-day course at equal dosage to that used in the ED (8–16mg) If possible, discharge patient with bridging dose (2–4mg)	N/A
Herring et al 2019^Citation34	Review article analyzing treatment options and different induction protocols for the use of buprenorphine in an ED setting	Uncomplicated Opioid Withdrawal COWS ≥ 8 COWS < 8 reassess in 1–2 hours	Initial: 4–8 mg (based on severity) Max: 32 mg	If X-waivered: prescribe max 16 mg SL buprenorphine/naloxone for 3–7 days or until appointment with outside addiction facility Provide patients with the highest level of care navigation and shortest appointment wait time	N/A
Bogan et al 2020^Citation22	Article reviewing the implementation of an emergency department-initiated buprenorphine program aimed at treating opioid use disorder	Presence of OUD COWS > 8 If COWS < 8 patients were excluded	Initial: 8 mg buprenorphine or 8:2 mg buprenorphine-naloxone Maximum: Not specified	All patients with OUD we offered naloxone kit upon discharge from ED Patient navigator arranged outpatient follow up within 24 hours of discharge	78% (187/241) showed up for initial outpatient visit. 59% (111/187) of those who showed up for initial visit were still in treatment at 30 days post discharge. Of the 535 patients eligible for naloxone kits 39% (209/535) elected to receive a kit.
Jaeger and Fuehrlein 2020^Citation33	Narrative review of the safety and efficacy of buprenorphine induction that is started in the ED	OUD established through history and physical COWS > 8 or subjectively ready	Initial: 2 or 4 mg Max: Not specified	Connecticut veterans hospital: Patients present daily to detox and stabilization service regardless of outpatient/inpatient or intensive outpatient follow-up	N/A
Carroll et al 2020^Citation35	Case-series that looks at the feasibility of using EMS to assess and treat OUD with buprenorphine in the field under the direction of a supervising physician	Presence of OUD X-waivered physician approval COWS > 7 or opioid free >72 hours	Initial: 16 mg Maximum: 24 mg	Patients may either be admitted to ED or refuse further care All patients provided with resources and next-day MAT clinic appointment	18 patients were administered buprenorphine through this protocol. 100% (18/18) demonstrated improvement of symptoms. 0% (0/18) demonstrated precipitated withdrawal.

Abbreviations: CDU, clinical decision unit; COWS, Clinical Opiate Withdrawal Scale; MINI, Mini-international Neuropsychiatric Interview; OOWS, Objective Opiate Withdrawal Scale; OUD, opioid use disorder; RCT, randomized control trial; SBIRT, screening brief intervention, and referral for treatment; SOWS, Subjective Opiate Withdrawal Scale.

Table 3 Models of Care for Transition from the Emergency Department to Medication-Assisted Treatment Programs

Author	Transition Model
Kaucher et al 2019^Citation20	Hub-and-spoke model where ED and hospital’s onsite MAT center served as hub and affiliated community providers were the spokes Patients initially treated at a hub Patients initiated in the ED were given next day follow up at the MAT clinic
Kelly et al 2019^Citation29	Social work follow-up in the ED after initial induction with buprenorphine Patients were screened for this study by MI and DSM-V to find patients with OUD who were motivated to engage in treatment SW worked with surrounding community teams to set up follow-up care for patients Outcome of study was patient engagement 30 days post ED course Also looked at ED length of stay, success rate of patients showing up to 1st outpatient appointment, and median number of days until this first outpatient follow up
Ahmed et al 2019^Citation39	Although not implemented, stakeholders suggest three recommendations for a successful warm hand-off: Designing “an automated, rapid, and flexible” referral system Quality assurance through aggregate metrics Providing urgent follow up with community clinics
Sholl et al 2019^Citation40	Social work driven process designed to lessen the burden on physicians in terms of arranging follow up for patients to community resources MAT centers, primary care, etc. Patients identified for eligibility for social worker by provider referral and nurse screening Physician involvement was decreased, only including brief screening and buprenorphine prescribing until follow up appointment
Kawasaki et al 2019^Citation41	All ED physicians waivered ED social workers schedule appointments within 1–2 days ED has a reliable after-care model consisting of a series of “spoke” clinics connected to a central “hub” Both spokes and the hub provide pharmacy and psychiatric services Higher acuity patients and more severe patients receive treatment at the hub. Integrated so that spoke clinics can refer to hub with minimal wait time If spoke or hub does not have time to initiate, patients can initiate at a partnered urgent care centers (bridge clinics) and return to spoke after This model allows for shorter wait time for higher risk patients Integrated peer-based recovery support services were also offered

Table 4 Barriers to Buprenorphine Induction in the Emergency Department

Author	Method	Barriers to Induction
Medcalf et al 2015^Citation51	27 ED physician responders to a 24-question survey sent to emergency physicians in one academic ED	Unfamiliarity with standardized methods of severity for acute opioid withdrawal. Unfamiliar with timing of buprenorphine in relation to moderate opioid withdrawal Unfamiliarity with prescribing indications and nuances Clinical volume combined with patient acuity Uncertainty with side effects
Hawk et al 2019^Citation47	Organizational Readiness to Change Assessment administered in three different hospitals settings. Followed by in-person focus groups with ED physicians, PA/APRNs, nurses, social workers, and community providers	Lack of experience with buprenorphine Difficulties with workflow integration Increased time needed to treat these patients. Limited knowledge of available treatment options for patients
Hernandez-Meier 2019^Citation48	21-question survey sent to 98 providers including physicians, physicians’ assistants, and nurse practitioners	Gaps in knowledge and understanding of buprenorphine induction in the ED Need for further education in pharmacology, dosages, efficacy, outcome information, and legal implications
Lowenstein et al 2019^Citation49	Cross-sectional survey of physicians in two EDs. These barriers are physician perceived	Lack of comfort counseling about buprenorphine Lack of comfort ordering buprenorphine Regulatory concerns Time constraints Concerns about diversion, misuse, and safety These concerns differed between X-waiver and non- X-waivered physicians
Martin et al 2019^Citation50	Semi-structured interviews with ED providers in a hospital with MAT protocol. Also interviewed 10 patients with OUD	Time pressure and lack of cues to know what to ask about opioid misuse Uncertainty with treatment protocols Uncertainty about responsibility of OUD treatment Patient focus on present not future Stigma surrounding treatment programs Mistrust of health system
Wiercigroch et al 2019^Citation52	Semi- structured interviews of 19 self-selected physicians at single Toronto ED	Provider inexperience causing missed subtle presentations of withdrawal Lacking feedback on treatment effectiveness Uncertainty about protocol from nursing staff Fast paced ED limits amount of time for counseling ED environment discourages taking up a bed to wait for withdrawal symptoms Worries about precipitating withdrawal Reluctance for prescribing chronic medications in acute setting
Hawk, McCormack et al 2019^Citation47	Focus groups of patients with OUD chosen from recent ED visits. 29 patients from Baltimore, NYC, Cincinnati, and Seattle.	Key themes from the focus groups Perception that ED staff did not understand OUD as a disease Dehumanizing experiences in the past due to OUD Long history of feeling stigmatized
Dora-Laskey and Sadler 2019^Citation57	Compared locations of MATs to that of emergency departments in Michigan.	Found that 43.5% of EDs had a MAT facility within 5 miles Found that 50.4% had a MAT facility within 10 miles Concluded that only half of Michigan’s EDs were within 10 miles of a MAT, limiting patients’ access to long term care

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