Drug overdoses are a leading cause of accidental death in the United States, representing a persistent and escalating health crisis. According to recent data from the Centers for Disease Control and Prevention (CDC), overdose deaths have exceeded 100,000 annually since 2021, with approximately 75 percent involving opioids—a proportion that continues to rise.¹

Even in nonfatal opioid overdose cases, there is a significant increase in both short- and long-term mortality. One study found a 5.5 percent mortality rate within one year among patients discharged from the emergency department (ED) following a nonfatal opioid overdose. Alarmingly, more than 20 percent of those deaths occurred within one month, and 4.6 percent occurred within just two days of discharge.² Another study revealed that patients who improved with naloxone after a nonfatal opioid overdose had a 13-fold increase in mortality within one year.³ These numbers underscore the impact of timely and effective intervention—both in the acute moments after an overdose, and in the days to months following ED discharge.

Buprenorphine, a partial opioid agonist approved for the treatment of opioid use disorder (OUD) by the U.S. Food and Drug Administration in 2002, is a cornerstone of evidence-based care for managing OUD. It effectively reduces cravings and withdrawal symptoms with minimal adverse effects. It is also proven to improve engagement in addiction treatment when compared to referral alone.⁴ These benefits translate into reductions in all-cause and opioid-related mortality.^5,6

Prehospital Bupe

Emergency medical services (EMS) often serve as the first point of contact with the health care system for many individuals experiencing overdose or withdrawal. The CDC reported that between January 2018 and March 2022, the rate of EMS responses for nonfatal opioid overdoses nearly doubled, from 98.1 to 179.1 per 10,000 EMS calls.⁷ Moreover, research has shown that nearly half of all individuals who suffer a fatal overdose had at least one EMS encounter in the preceding year.^8,9 It is clear these encounters are critical moments for potential intervention.

Across the country, a growing number of EMS systems recognize and embrace this opportunity to bring lifesaving and symptom-improving treatment to patients before they  reach the hospital.^10,11 Paramedics—and, in some places, even EMTs—are being trained to assess patients for buprenorphine eligibility and administer the medication in the prehospital setting. This is particularly important because studies have found that up to 47 percent of patients decline EMS transport to the hospital after being revived from an overdose.^12,13,14 For these individuals, the brief EMS encounter could be their sole interaction with the health care system. It may be their only chance to initiate OUD treatment, receive counseling, and get connected to follow-up care.

Administering buprenorphine in the field has proven to be as safe and effective as starting it in the ED. When guided by standardized protocols and tools like the Clinical Opiate Withdrawal Scale (COWS), the risk of precipitated withdrawal is low to none, comparable to in-hospital initiation.^12,15 Additionally, studies demonstrate that EMS-initiated buprenorphine, like ED-based initiation, is associated with improved engagement in addiction treatment at 30 days.^15,16 These are crucial factors for encouraging long-term recovery.

Protocols vary across agencies for EMS-driven buprenorphine administration, reflecting differences in agency structure as well as local resources and regulations. Some systems go beyond medication delivery to include direct transport to a substance-use treatment facility rather than the hospital, while others incorporate peer recovery specialists or social workers into the EMS response teams. These models recognize the value of meeting individuals where they are, both literally and figuratively, taking advantage of the unique position EMS holds. Many states have developed model EMS protocols and offer targeted training to facilitate adoption while ensuring patient safety.

Innovative changes like these align with national efforts to expand access to evidence-based OUD treatment, alongside policy changes such as the elimination of the X-waiver requirement and the increasing promotion of low-threshold treatment models. These developments open the door for broader buprenorphine access, even in non-traditional settings like the back of an ambulance.

For emergency physicians, this growing EMS capability has practical implications. Although not all EMS agencies are yet equipped to administer buprenorphine, the number of participating systems is increasing, and EDs may begin to see more patients who have already received their first dose before arrival. Coordinated care between prehospital and emergency teams can ensure continuity of treatment, reduce duplication of efforts, and improve overall patient outcomes.

Emergency physicians and EMS workers share a common mission: to reduce harm and save lives in the midst of the opioid crisis. Buprenorphine initiation in the prehospital setting is a powerful tool in this fight. By transforming a response to an overdose reversal into a gateway toward recovery, EMS agencies are shifting the trajectory of care. Emergency physicians can support these efforts, collaborate with our prehospital partners, and extend the reach of lifesaving treatment beyond the walls of the ED.

Dr. Chung is a PGY-4 resident in emergency medicine at George Washington University in Washington, DC.

References

1. Centers for Disease Control and Prevention, National Center for Health Statistics. National Vital Statistics System, Mortality 2018-2023. CDC WONDER Online Database. Released 2024. Accessed May 23, 2025. Available at: https://wonder.cdc.gov/
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