Buprenorphine in the Emergency Department

What forms of buprenorphine should we have on the formulary?

At minimum, sublingual tablet formulations of buprenorphine should be available to be administered and/or prescribed from the ED. The most common formulations are sublingual (alone or in combination with naloxone: Suboxone), transdermal (10mcg/hr = about 0.5mg/day), and intravenous (Buprenex).

When do you administer buprenorphine in the ED?

Buprenorphine will displace other drugs from opioid receptors, replacing the high-intensity stimulation from drugs like heroin or oxycodone with stable drug levels over 2-3 days, eliminating craving and withdrawal symptoms. Starting BUP when patients have moderate withdrawal symptoms provides immediate relief, stopping withdrawal discomfort without causing euphoria or sleepiness. Do NOT start BUP on opioid-dependent patients who are not in withdrawal. For these patients, the BUP causes withdrawal, and decreases patients’ desire to stay on BUP or to try BUP again.

How does a clinician give buprenorphine in the ED?

Generally start with  4-8 mg as sublingual tablet (Suboxone or Subutex) under the tongue. IV BUP (0.3mg ) can be used for patients unable to tolerate sublingual tablets. If the tablets are swallowed, very little BUP gets absorbed.  Repeat doses up to 32mg SL can be administered depending on the clinical situation. It is okay to administer BUP in low-acuity, “fast-track” type areas of the ED. A single 8 mg dose will have peak effect by about 1 hour and control withdrawal symptoms 6-12 hours. Transdermal buprenorphine will generally be too weak to prevent withdrawal symptoms and is best used for patients with chronic pain. See ED-BRIDGE Guide to Emergency Buprenorphine Treatment.

How should an ED discharge a patient?

Always offer a naloxone prescription or kit.

  • Option 1. No DEA X waiver: Prescribe comfort meds (e.g. clonidine, loperamide, ondansetron, NSAIDS) and recommend follow-up at treatment center. It is legal in all states to offer return ED visits for BUP administration for 3 days in a row if necessary.

  • Option 2. DEA X waiver: Give bridge script to last until outpatient visit: e.g., 8mg Suboxone, SL tabs; Take 1 tab under the tongue twice a day for withdrawal symptoms; Dispense #6-7