Buprenorphine Induction in the ED: Innovations in the Treatment of Opioid Use Disorder

Katherine Rodman, MSIV
Oregon Health & Sciences University Medical School
EMRA MSC Pacific Regional Representative
David Jones, MD
Associate Professor of Emergency Medicine,
Oregon Health & Science University Medical School

The United States has experienced an escalating crisis of opioid addiction and misuse. While the number of deaths related to overdose have steadily increased over the past two decades, treatment has not advanced at the same pace. Medication for Addiction Treatment (MAT), which utilizes opioid agonists to support detoxification, has been a staple of opioid addiction treatment for decades. However, public perceptions and legislation have hindered its access and application. Methadone, an opioid agonist first created in the 1930s, has been shown to be more effective at retaining patients in treatment, decreasing days of opioid use, and decreasing mortality compared to placebo. Newer on the medical scene is buprenorphine which is a partial opioid agonist with a different pharmacokinetic profile than methadone. As it is a partial agonist, buprenorphine has a “ceiling effect” that makes it more difficult to misuse than other opioids. The most common form of buprenorphine actually comes in combination with another drug, naloxone, and is known as suboxone. Naloxone is an opioid antagonist, so it binds opioid receptors and prevents other opioids such as oxycodone or heroin from binding thereby preventing or dampening the “high” of these drugs.

While we have these drugs available, access to MAT can still be difficult. Methadone treatment is difficult to administer because it must be administered from a specialized methadone clinic or a medical facility that has a methadone clinic associated with it, and it must be prescribed daily. This is a large logistical undertaking for patients as they have to have transportation to get to methadone clinics and have time every day to do so. Understandably, compliance becomes an issue. The driving force behind methadone’s legal hoops is concern for abuse. Buprenorphine on the other hand, has lower propensity for abuse due to its pharmacokinetics, and so it can sometimes be prescribed at longer intervals. However, prescriber restrictions still exist for buprenorphine. In order to prescribe the medication the prescriber must have a DEA X-Waiver, and even with a waiver the number of patients they can prescribe to is limited.

To increase engagement in treatment medical providers have been strategizing new programs and outreach to increase access to MAT. One area of focus has been emergency departments (EDs). For many patients who misuse opioids, EDs are an important point of engagement with the medical system, which makes it a prime location to engage patients in treatment. There have been a number of randomized controlled trials to evaluate the efficacy of initiating patients on buprenorphine while in the ED. The first such trial, performed at Yale, showed that patients who received buprenorphine in the ED and were referred to a 10-week treatment course of buprenorphine in the community were more likely to be engaged in treatment at 30 days and report fewer days of opioid use. Other studies also saw increased retention in treatment after ED-initiated buprenorphine. This approach to treatment has also been shown to be more cost effective than referrals to community centers alone.

Based on the knowledge that ED-initiated buprenorphine treatment can be an effective way to engage patients with MAT, many emergency departments across the United States have begun programs where patients in opioid withdrawal can be initiated on buprenorphine with the goal being to transition to longer term treatment. First doses of buprenorphine are administered during their ED visit and they can be prescribed a short-term course to bridge them to outpatient treatment –as long as the provider is X-waivered. It is important to note that an X-waiver is not required to order and administer buprenorphine within the ED; it is only needed in order to prescribe. This is a common point of misconception and often prevents the initial administration of buprenorphine. While Yale was likely the first academic center to begin a buprenorphine program, many other institutions have followed. California alone has over 50 emergency departments participating in buprenorphine treatment through the CA Bridge program. Many large academic centers including Harvard, Penn, Cornell, and Oregon Health & Science University are also following suit. Recently, the NIH has launched a $945 million initiative HEAL (Helping to End Addiction Long-term) which will investigate implementation of buprenorphine and the efficacy of different implementation strategies including ED initiated therapy.

While large initiatives such as HEAL are in their early stages, it is reassuring to see that research into opioid use disorder is receiving the attention it needs. Due to the difficulties of treatment including frequent visits for prescriptions and high incidence of relapse, opioid use disorder will remain a large and prevalent issue within the medical community, and our society as a whole. Hopefully with more innovative approaches like ED-initiated buprenorphine, the medical community can better connect with and provide treatment to those in need.

To have an X-waiver, an 8-hour course is required. Medical students that complete this course through ACEP are eligible to apply for a DEA X number when they obtain their DEA license.

References

1. Drug Overdose Deaths. Center for Disease Control and Prevention. https://www.cdc.gov/drugoverdose/data/statedeaths.html
2. Mattick RP, Breen C, Kimber J, Davoli M. Methadone maintenance therapy versus no opioid replacement therapy for opioid dependence. Cochrane Database Syst Rev. 2009;(3):CD002209. Published 2009 Jul 8. doi:10.1002/14651858.CD002209.pub2
3. D'Onofrio G, O'Connor PG, Pantalon MV, et al. Emergency department-initiated buprenorphine/naloxone treatment for opioid dependence: a randomized clinical trial. JAMA. 2015;313(16):1636-1644. doi:10.1001/jama.2015.3474
4. Kaucher KA, Caruso EH, Sungar G, et al. Evaluation of an emergency department buprenorphine induction and medication-assisted treatment referral program. Am J Emerg Med. 2020;38(2):300-304. doi:10.1016/j.ajem.2019.158373
5. Busch SH, Fiellin DA, Chawarski MC, et al. Cost-effectiveness of emergency department-initiated treatment for opioid dependence. Addiction. 2017;112(11):2002-2010. doi:10.1111/add.13900