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Treating Opioid Withdrawal in the ED with Buprenorphine: A Bridge to Recovery

buprenorphineThe Emergency Department (ED) is the frontline of the opioid crisis, treating patients with opioid-related infections, opioid withdrawal, and overdose. These encounters can be difficult or even downright confrontational. But that does not have to be the case! With the use of buprenorphine, we can “flip the script” for these encounters, encouraging patient-provider collaboration in the treatment of opioid addiction as medical disease.

Background

Buprenorphine is the first-line treatment for opioid use disorder,1 as it significantly reduces mortality,2,3 increases subsequent addiction treatment,4 and reduces ED utilization.5 It is a long-acting, high affinity, intermediate agonist. It binds with the mu-opioid receptors to keep a patient from withdrawal, but does not activate receptors strongly enough to provide a euphoric high, heavily sedate patients, or significantly depress the respiratory drive.6–8 This ceiling effect makes overdoses from buprenorphine extremely rare, even at very high doses. Therefore, it is much safer than the opioids we often give. Buprenorphine can be administered in the ED by any DEA-licensed provider, although the X-waiver is additionally needed to prescribe buprenorphine.

But why should the ED get involved?

Isn’t this better done by outpatient providers?

It is surprisingly difficult for patients to find providers who offer buprenorphine, and even when they do, there may be a long wait. The ED is an ideal setting to reach patients with opioid addiction and engage them in care. It is open 24/7 and may be the only contact that opioid users have with the healthcare system. Starting buprenorphine in the ED nearly doubles the likelihood4 that patients will follow-up with addiction treatment than referral alone.

Addiction is a medical disease, just like diabetes or hypertension, and withholding treatment is quite deadly. In Massachusetts, about 10% of patients who were given naloxone by prehospital providers for an overdose later died within 1 year.9 If we have a medication that reduces that risk of death, we should be using it.

Ok, I’m interested, but when and how do I do give buprenorphine?

The next time you have a patient in opioid withdrawal, you can use the Clinical Opiate Withdrawal Score (COWS) tool to quantify the level of severity. If the patient has a COWS of ≥8 with an objective sign of withdrawal, give 8 mg of sublingual buprenorphine. No labs are needed. In 30-60 minutes, if they are feeling better, give a second dose.

ED-Bridge Buprenorphine Guideline (Algorithm authors: Andrew Herring, MD; Hannah Synder, MD; Aimee Moulin, MD; Arianna Sampson, PA-C; Josh Luftig, PA; Sarah Windels; Rebecca Trotzky, MD; Melody Glenn, MD; David Kan, MD; James Gasper, PharmD, BCPP; Kathy Vo, MD; Craig Smolin, MD)

Severe withdrawal is actually the easiest to treat, as the patient has usually gone at least 24 hours since their last use, and thus all opioids have washed out of their system. This patient can be rapidly titrated to a therapeutic level (16-32 mg) without concern for precipitated withdrawal.

Before discharge, refer to a local clinic that offers buprenorphine maintenance.

Starting a Buprenorphine Program: Our Community ED Experience

Starting our program at Sutter Delta was surprisingly painless. After presenting the efficacy and safety data around buprenorphine, it was easy to get buy-in from hospital, ED, pharmacy, and nursing leadership. Buprenorphine was already on formulary, so we didn’t have to go through the Pharmacy and Therapeutics Committee. We just added it to the Pyxis medication dispensing stations. We laminated a version of the ED Bridge protocol customized for our site and placed it in the ED (along with the COWS scoring system on the backside of the page). We trained physicians, advanced practice providers, and nurses how to assess withdrawal and give buprenorphine.

When an eligible patient arrives in the ED, they are seen and treated from fast-track, as they don’t need any labs. The scribe then calls our referral clinic, which has already agreed to see the patient on the next day, and leaves a HIPAA-compliant voicemail about the patient. Codifying the referral process in detail may be the most important component of starting a program. Initial quality improvement follow-ups have found that these patients have all started addiction treatment and are happy with the care they received.

Going Forward

For further resources to help turn your ED into a buprenorphine center of excellence, check out the following site: ED-Bridge.org. They have tons of resources to help with education and logistics, including online office hours to answer any questions you might have about buprenorphine.

1.
Bruneau J, Ahamad K, Goyer M-È, et al. Management of opioid use disorders: a national clinical practice guideline. C. 2018;190(9):E247-E257. doi:10.1503/cmaj.170958
2.
Hickman M, Steer C, Tilling K, et al. The impact of buprenorphine and methadone on mortality: a primary care cohort study in the United Kingdom. A. April 2018. doi:10.1111/add.14188
3.
Sordo L, Barrio G, Bravo MJ, et al. Mortality risk during and after opioid substitution treatment: systematic review and meta-analysis of cohort studies. B. April 2017:j1550. doi:10.1136/bmj.j1550
4.
D’Onofrio G, O’Connor PG, Pantalon MV, et al. Emergency Department–Initiated Buprenorphine/Naloxone Treatment for Opioid Dependence. J. 2015;313(16):1636. doi:10.1001/jama.2015.3474
5.
Schwarz R, Zelenev A, Bruce RD, Altice FL. Retention on buprenorphine treatment reduces emergency department utilization, but not hospitalization, among treatment-seeking patients with opioid dependence. J. 2012;43(4):451-457. doi:10.1016/j.jsat.2012.03.008
6.
Dahan A, Yassen A, Romberg R, et al. Buprenorphine induces ceiling in respiratory depression but not in analgesia. Br J Anaesth. 2006;96(5):627-632. [PubMed]
7.
Umbricht A, Huestis M, Cone E, Preston K. Effects of high-dose intravenous buprenorphine in experienced opioid abusers. J Clin Psychopharmacol. 2004;24(5):479-487. [PubMed]
8.
Walsh S, Preston K, Stitzer M, Cone E, Bigelow G. Clinical pharmacology of buprenorphine: ceiling effects at high doses. Clin Pharmacol Ther. 1994;55(5):569-580. [PubMed]
9.
Weiner SG, Baker O, Bernson D, Schuur JD. 402 One-Year Mortality of Opioid Overdose Victims Who Received Naloxone by Emergency Medical Services. A. 2017;70(4):S158. doi:10.1016/j.annemergmed.2017.07.281
Mac Chamberlin, MD

Mac Chamberlin, MD

Emergency Medicine Resident
Highland Hospital
Andrew Herring, MD

Andrew Herring, MD

Emergency Physician
Associate Research Director
Highland Hospital
ED-Bridge
Josh Luftig, PA

Josh Luftig, PA

Emergency Medicine Physician Assistant
Highland Hospital
ED-Bridge
Melody Glenn, MD

Melody Glenn, MD

Emergency Physician
Highland Hospital
Sutter Delta Medical Center
Workit Health