Treatments That Work for Patients

OUD patients presenting to the emergency department and to EMS, whether after an overdose or due to medical complications related to opioid use, are at extraordinary risk for short-term mortality. Emergency providers can have a significant impact on outcomes by initiating buprenorphine treatment and referring patients for ongoing medication-based addiction care. However, traditional time-intensive initiation models are discordant with emergency care, where we often have only a brief window to engage these patients, especially patients in withdrawal, who are very likely to decline further care and leave.

Most patients find withdrawal symptoms intolerable, and despite being given a buprenorphine prescription at discharge, many are unable to bear the development of severe enough OWS to initiate buprenorphine at home using a conventional gradual dosing strategy. Treating precipitated withdrawal with high-dose buprenorphine has the potential to close this treatment gap by quickly relieving withdrawal symptoms without the fear of precipitated withdrawal. Administration of 16–24 mg of buprenorphine binds a high fraction of the patient’s opioid receptors, which decreases cravings, prevents withdrawal, and protects the patient from opioid overdose for 24 hours or longer. Initiating high-dose buprenorphine to ED and EMS patients with low Clinical Opiate Withdrawal Scale scores may therefore allow successful transition to buprenorphine recovery among a group of patients who would otherwise fail to establish therapy.

Though these strategies are in their infancy, they have thus far been demonstrated to be safe and effective. While more experience and outcome data are needed, treatment of precipitated withdrawal with high-dose buprenorphine has the potential to significantly expand the reach of emergency providers at the front lines of addiction care. 

Dr. Haroz is assistant professor of emergency medicine at Cooper Medical School of Rowan University and division head, toxicology and addiction medicine, in the department of emergency medicine at Cooper University Health Care in Camden, New Jersey.

Dr. Carroll is assistant professor of emergency medicine and EMS fellowship director at Cooper Medical School of Rowan University and medical director, division of EMS and disaster medicine, in the department of emergency medicine at Cooper University Health Care.

Dr. Strayer is associate medical director of emergency medicine at Maimonides Medical Center in Brooklyn, New York.