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    Buprenorphine/Naloxone Initiation for ED Patients Who Use Opioids

    Substance Use, Toxicology

    Last Reviewed on May 27, 2021
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    Context

    Clinical Summary for use with BC Decision Support Tool Flow Diagram (Source: LOUD in the ED Collaborative).

    • EDs are sadly often the last point of contact with the healthcare system for people at risk of opioid overdose/poisoning and related death.
    • ED patients with opioid use disorder (OUD) have a 5-10% 1-year mortality. Opioid agonist treatment (OAT) can reduce this by half.  It also reduces transmission of HIV/HCV.
    • Buprenorphine/Naloxone (BUP) is considered 1st line OAT over methadone due to a better safety profile.
    • Initiation of BUP from the ED doubles retention in treatment at 30 days.

    Eligibility for OAT

    • Screen patients who use opioids (illicit or prescribed), experience withdrawal/overdose or other related presentations (abscess/cellulitis).
    • Have OUD: 2+ criteria from DSM-5 needed (e.g. withdrawal, physically hazardous use, etc).
    • Patient not currently on OAT and interested in treatment.
    • For more complicated initiations (e.g., pregnancy), call your local addiction team, or the BC 24/7 Support Line.

    Recommended Treatment: ED Initiation

    • Situation
      • Clinical Opiate Withdrawal Scale (COWS) score >12 (moderate to severe withdrawal).
      • >12 H since last immediate release opioids OR >24 H if known/suspected fentanyl.
      • If patient willing & ED space available, ED observation until COWS>12.
    • Steps
      • Counsel on BUP benefits and the risk of precipitated withdrawal.
      • Start with BUP 2mg SL test dose. Allow tab to dissolve fully for 10-15 min.
      • Administration tips: No food/smoking/liquids 15 minutes pre- & post-dose. Pre-moisten mouth with water if dehydrated.
      • If symptoms not worse or improving, 2mg SL Q1H until withdrawal symptoms tolerable or to max of 12-16mg and at times >16mg based on patient comfort & provider discretion (N.B.: >12 mg off label for Day 1).
      • If patient feels significantly worse, assess for precipitated withdrawal.
      • If symptoms improving but not resolved, can discharge patient to complete induction in community with “to-go” doses to reach day 1 target total dose.

    Recommended Treatment: Community Initiation (Unobserved)

    • Situation
      • Not in moderate/severe withdrawal, support in community setting.
    • Steps
      • Counsel on BUP benefits and the small risk of precipitated withdrawal.
      • Provide patient education & instructions for initiation (see example).
      • Provide BUP to-go initiation pack or prescription; 1-5 day supply until able to connect with community prescriber
      • Day 1 similar to ED initiation titration.
      • Day 2-5 BUP as once-daily dosing 12-16 mg SL (higher retention at higher dose).
      • Provide medications (e.g., ibuprofen, dimenhydrinate, clonidine) to treat withdrawal symptoms until ready for initiation.

    Adverse Effect: Precipitated Withdrawal

    • Situation
      • BUP taken too early leads to rapid onset of severe withdrawal.
    • Steps
      • Treat withdrawal symptoms aggressively (e.g., NSAIDs, anti-emetics, anxiolytics).
      • Provide reassurance and support (symptoms are temporary).
      • Shared decision making among 3 options:
        • Continue: BUP will eventually provide relief but may worsen symptom duration and severity.
        • Delay: Wait a few hours until withdrawal abates, then resume.
        • Stop: Consider high-affinity rescue opioids (e.g. hydromorphone) if patient is in significant distress and not interested in continuing BUP.

    Transition of Care (Discharge Planning)

    Need Help?

    Watch this space: BUP Microdosing

    • Alternative approach that eliminates need for withdrawal prior to initiation
    • Off label approach used in community & under study in ED settings

    Quality Of Evidence?

    Justification

    Clinical Expert Review; RCTs.

    High

    Related Information

    OTHER RELEVANT INFORMATION

    Reference List

    Relevant Resources

    RELEVANT CLINICAL RESOURCES

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    RELEVANT VIDEO

    02:17

    Buprenorphine Induction

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