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

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