• Screen for and identify ED patients who use opioids, as part of general ED substance use screening
• Identify and treat opioid withdrawal early
• Ensure that primary medical reason for visit is addressed
• Offer buprenorphine/naloxone (BUP) to patients who have opioid use disorder (OUD) but are not on opioid agonist therapy (OAT)

• People who use opioids visit EDs frequently. ED patients presenting with opioid intoxication have a 5-10% 1-year mortality.
• BUP initiation in the ED can increase retention and engagement in treatment.
• OAT is recommended for all patients with OUD due to associated reduction in mortality and transmission of HIV/HCV.
• BUP’s favorable safety profile (i.e. less respiratory depression) makes it well-suited to ED initiation

• Inquire about current opioid use among patients who used opioids in the past (unregulated or prescribed), presented with opioid withdrawal or overdose, or have conditions that may be associated with substance use (recurrent skin and soft tissue infections)
• Diagnose OUD: 2+ criteria within the last 12 months from DSM-5-TR needed (e.g., withdrawal, consequences related to use, etc.). Those without tolerance/withdrawal typically not BUP candidates.
• Verify that patient not currently on OAT and interested in treatment.
• For more complicated initiations (e.g., pregnancy/breastfeeding, switch from other OAT, severe liver disease, youth, or concurrent severe alcohol/sedative use disorder ), call your local addiction team or the BC 24/7 Support Line

ED BUP Initiation

There are 3 options:

1. Low-Dose (or micro-dosing) initiation (preferred by many patients)
2. Traditional dosing initiation in the ED (requires moderate to severe withdrawal)
3. Traditional dosing initiation at home with a to-go pack

Low-Dose Induction (Micro-dosing)

• Situation: Patient prefers to avoid experiencing withdrawal
• Patient does not need to be in withdrawal to start BUP and should continue using opioids until induction is complete (unregulated and/or prescribed) to avoid opioid withdrawal
• Review safer use with all patients, consider providing bridging prescribed concurrent full agonist if within your expertise
• Provide low-dose buprenorphine to-go pack or prescription: common protocols over 5–7 days, with BID to QID dosing (there have been no studies comparing protocol effectiveness)
• Provide and review micro-dosing patient instructions
• Low risk of precipitated withdrawal

Traditional dosing initiation in the ED

• Situation: Patient arrives in ED in opioid withdrawal
• Clinical Opiate Withdrawal Scale (COWS) score must be >12 (moderate withdrawal) to start*

*May initiate regardless of COWS if history and timeline suggest withdrawal is subsiding or resolved (typically >72hrs since last use)

1. If patient willing and ED space available, ED observation until COWS > 12
2. Consider COWS >16-18 if patient using fentanyl regularly
3. >12 hrs since last immediate release opioids (e.g., heroin, oxycodone, hydromorphone) except fentanyl (see below)
4. >24 hrs since intermediate-acting opioids (e.g M-Eslon) or last known/suspected fentanyl
5. If methadone or Kadian within 4 days, this is OAT switch & requires specialist consultation

• Steps

1. Obtain verbal informed consent: counsel on BUP benefits, anticipated course of treatment and risk of precipitated withdrawal
2. Provide medications (e.g., acetaminophen, ibuprofen, dimenhydrinate, ondansetron, clonidine, loperamide) to treat opioid withdrawal symptoms until ready for initiation.
3. COWS monitoring:
   • Pre-induction in ED: Q2h until score > 12
   • During ED induction: pre-dose for all doses and 1hr post first 3 doses
4. Start with BUP 2mg SL test dose. Allow tab to dissolve fully under tongue for 10-15 min.
5. Administration tips: No food/smoking/liquids 15 minutes pre- & post-dose. Pre-moisten mouth with water if dehydrated. Ensure patient does not swallow undissolved tabs.
6. If patient feels markedly worse/COWS increasing, address precipitated withdrawal (see below)
7. If symptoms unchanged or improving, continue 2mg SL Q1H until withdrawal symptoms resolved or to max of 16mg*
   • *If ongoing withdrawal symptoms and/or cravings , consider up to 24 mg at provider discretion on day 1
8. Once therapeutic or max dose achieved, prescribe a once daily dose equivalent to total induction dose (e.g., 16mg SL daily), or provide to-go kit with instructions for daily dose.
   • Provide or prescribe # days needed until (and including) follow-up with community prescriber
9. If patient wishes to leave and symptoms improving but not resolved, can discharge patient to complete induction in community with “to-go” doses (either dispensed or prescribed) to reach Day 1 target total dose.

Traditional dosing initiation at home with to-go-pack (aka unobserved community initiation)

• Situation: Patient not in moderate/severe withdrawal, has support in community setting, feels can tolerate withdrawal and follow discharge instructions for initiation

1. Counsel on BUP benefits and risk of precipitated withdrawal
2. Provide patient education and instructions for initiation (these include self-assessment of moderate to severe withdrawal)
3. Provide BUP to-go initiation pack or prescription; 1-7 day supply until able to connect with community prescriber
4. Day 1 similar to ED initiation titration (see above)
5. Day 2+ prescribe (or provide) once daily dosing until sees OAT provider (e.g., 16 mg SL daily)
6. Provide medications (e.g., ibuprofen, dimenhydrinate, clonidine) to treat withdrawal symptoms until ready for initiation.

• Situation
  • BUP taken prior to sufficient withdrawal and/or time since last opioid leads to rapid onset of severe withdrawal (i.e., BUP partial agonist with high receptor affinity displaces full agonist)
  • Can be associated with loss to treatment and/or refusal of BUP in the future
• Steps
  1. Treat all patients with non-opioid medications (e.g., clonidine, NSAIDs, antiemetics, anxiolytics)
  2. Acknowledge the diagnosis, provide reassurance and support
     • Unlikely to get full symptom resolution on first day
  3. Shared decision making among 2 options*:
     • Stop: Offer non-opioid adjuncts and/or short-acting high affinity opioids (eg hydromorphone) to treat withdrawal symptoms as needed & make follow-up OAT initiation plan)
     • Push: off-label and emerging approach without consensus on dose): high-dose BUP. Additional doses of BUP (8-16mg) in close succession ranging from 8-32+mg total.  Call for addiction support if first time using “push” approach. See ‘macrodosing’ information. For possible “push” approach in special situations (withdrawal post naloxone or naltrexone), specialist phone advice advised.
     • *“Pause” option no longer recommended, i.e., waiting a few hours until withdrawal abates, then resume up to Day 1 maximum or until withdrawal symptoms resolve.
  4. Addiction support: local addiction consult team, BC 24/7 Support Line or RACEapp

• Follow transition of care checklist (VCH example), including take-home naloxone kit for all, BUP to-go initiation pack and/or discharge prescriptions
• Referral to OAT clinic (OAT Clinics Accepting New Patients) or bridging clinic (RAAC, POTA, lighthouse)

• BCCSU 24/7 Addiction Medicine Clinician Support Line: 778-945-7619

1. Buprenorphine/Naloxone 2023 Clinical Summary Guidance (community practice, not ED focus)

    

   
   

2. Opioid Use Disorder Care in the Emergency Department

   
   

3. ECBC Patient Information Sheet

   VCH SURKit

   LOUD in the ED BUP Induction Decision Support Tool

   
   

4. PHSA LearningHub Course on BUP.
   Toward the Heart Take Home Naloxone.
   Provincial Opioid Addiction Treatment Support Program Course (acute care stream).

   
   

1. British Columbia Centre on Substance Use and B.C. Ministry of Health. A Guideline for the Clinical Management of Opioid Use Disorder – 2023 Update. British Columbia Centre on Substance Use; 2023. Accessed June 1, 2024. 

    

   
   

2. D’Onofrio G, O’Connor P, Pantalon M, et al. Emergency Department-Initiated Buprenorphine/Naloxone Treatment for Opioid Dependence, A Randomized Trial. JAMA. 2015;16(313):1636–1644.

   
   

3. Moe J, Chong M, Zhao B, Scheuermeyer FX, Purssell R, Slaunwhite A. Death after emergency department visits for opioid overdose in British Columbia: a retrospective cohort analysis. CMAJ Open. 2021 Mar 17;9(1):E242-E251.

   
   

4. Moe J, Badke K, Pratt M, Cho RY, Azar P, Flemming H, Sutherland KA, Harvey B, Gurney L, Lockington J, Brasher P, Gill S, Garrod E, Bath M, Kestler A. Microdosing and standard-dosing take-home buprenorphine from the emergency department: A feasibility study. J Am Coll Emerg Physicians Open. 2020 Oct 20;1(6):1712-1722.