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. 2021 Nov 29;2(6):e12606.
doi: 10.1002/emp2.12606. eCollection 2021 Dec.

Emergency department-initiated buprenorphine protocols: A national evaluation

Clara Z Guo  1 , Gail D'Onofrio  2 , David A Fiellin  3 , E Jennifer Edelman  3 , Kathryn Hawk  2 , Andrew Herring  4 , Ryan McCormack  5 , Jeanmarie Perrone  6 , Ethan Cowan  7
Affiliations

Emergency department-initiated buprenorphine protocols: A national evaluation

Clara Z Guo et al. J Am Coll Emerg Physicians Open. .

Abstract

Objective: Emergency department-initiated buprenorphine (BUP) for opioid use disorder is an evidence-based practice, but limited data exist on BUP initiation practices in real-world settings. We sought to characterize protocols for BUP initiation among a geographically diverse sample of emergency departments (EDs).

Methods: In December 2020, we reviewed prestudy clinical BUP initiation protocols from all EDs participating in CTN0099 Emergency Department-INitiated bupreNOrphine VAlidaTION (ED-INNOVATION). We abstracted information on processes for identification of treatment-eligible patients, BUP administration, and discharge care.

Results: All participating ED-INNOVATION sites across 22 states submitted protocols; 31 protocols were analyzed. Identification of treatment-eligible patients: Most EDs 22 (71%) relied on clinician judgment to determine appropriateness of BUP treatment with only 7 (23%) requiring decision support tools or diagnosis checklists. Before BUP initiation, 27 (87%) protocols required a documented Clinical Opiate Withdrawal Scale (COWS) score; 4 (13%) required a clinical diagnosis of withdrawal with optional COWS score. Twenty-seven (87%) recommended a minimum COWS score of 8 for ED-initiated BUP. BUP administration: Initial BUP dose ranged from 2-16 mg (mode = 4). For continued withdrawal symptoms, 27 (87%) protocols recommended an interval of 30-60 minutes between first and second BUP dose. Total BUP dose in the ED ranged from 8 to 32 mg. Discharge care: Twenty-eight (90%) protocols recommended a BUP prescription (mode 16 mg daily) at discharge. Naloxone prescription and/or provision was suggested in 23 (74%) protocols.

Conclusions: In this geographically diverse sample of EDs, protocols for ED-initiated BUP differed between sites. Future work should evaluate the association between this variation and patient outcomes.

Keywords: buprenorphine protocol; emergency department; opioid use disorder; opioid withdrawal.

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Conflict of interest statement

The authors declare no conflict of interest.

Figures

FIGURE 1
FIGURE 1
Location of emergency department sites that were selected to participate in CTN 0099 ED‐INNOVATION (n = 33). Sites that submitted protocols and were selected to participate in the National Institute on Drug Abuse Clinical Trials Network (NIDA CTN) 0099 Emergency Department‐INitiated BupreNOrphine VAlidaTION Trial Network (ED‐INNOVATION) study are indicated by blue circles (n = 33). The 33 sites represented 22 states; overlapping circles include 2 in California, 2 in Illinois, 2 in Michigan, 2 in New Mexico, 3 in Pennsylvania, and 2 in Washington. Abbreviations: BUP, buprenorphine; COWS, Clinical Opiate Withdrawal Scale; ED, emergency department; OUD, opioid use disorder
FIGURE 2
FIGURE 2
Framework for ED‐initiated buprenorphine Abbreviation: EMR, electronic medical record
See this image and copyright information in PMC

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