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    Buprenorphine/Naloxone Initiation for ED Patients Who Use Opioids

    Substance Use, Toxicology

    Last Updated May 27, 2021
    Read Disclaimer
    By Andrew Kestler, Jason Wale, Melissa Allan, Jessica Moe, Isabelle Miles, LOUD in the ED Collaborative


    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?


    Clinical Expert Review; RCTs.


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