“Opioid overdose continues to be the leading cause of death due to injury in the US. Recent data from the Drug Abuse Warning Network estimated 882 000 emergency department (ED) opioid-related visits in 2023, a rate of 263 per 100 000 visits, with the highest rates among Black individuals (425 per 100 000). Access to treatment with medications for opioid use disorder, specifically buprenorphine, continues to be challenging for patients in active addiction, and these disparities by race are widening. [..] In many states, rural patients with opioid use disorder have worse outcomes than urban patients. Rural hospitals are also less likely to offer treatments, such as addiction medicine consultation and medications for opioid use disorder. Thus, the ED is a logical setting to provide equitable substance use treatment access and medication initiation, yet it continues to be underused and underfunded.
In this issue of JAMA, Dekker and colleagues report a notable increase from 0.1% (2017) to 5% (2022) in ED-initiated buprenorphine prescribing by California emergency clinicians following incremental state investments to facilitate and expand the CA Bridge program. Moreover, 1 in 3 new ED buprenorphine initiation prescriptions was followed by a second prescription, demonstrating that ED buprenorphine initiation can be a meaningful start to a sustained period of lifesaving treatment. The authors also demonstrate a change in emergency medicine culture in California; the annual number of ED buprenorphine prescribers increased annually from 78 in 2017 to 1789 in 2022, suggesting that ED buprenorphine prescribing has become a standard practice in California emergency medicine. Notably, these increases came before the 2023 removal of the Drug Enforcement Administration (DEA) Drug Addiction Treatment Act of 2000 X-waiver, a now-retired special DEA registration that required 8 hours of training to earn an “X” designation on a practitioner’s DEA number to authorize buprenorphine prescribing for opioid use disorder, thus demonstrating a commitment by California emergency clinicians to this underserved and vulnerable population. [..]
There are some limitations to consider in the work of Dekker et al, as this is a retrospective observational study using the California Controlled Substance Utilization Review and Evaluation System (CURES), with no availability of other outcome data such as subsequent overdose rates or mortality, nor a control group. [..]
Imagine if all EDs across the US were supported by investments in improving adoption of buprenorphine by providing training, technical assistance, and funding for development of programs with patient navigators and harm reduction strategies similar to those by the CA Bridge program. Since 2018, 291 (92%) of 316 EDs located in licensed acute care hospitals in California have been funded with approximately $75 000 to 250 000 per ED, for a total of $93 million in programmatic and technical assistance. This infrastructure, both virtual and physical, provides aid to patients in the form of substance use navigators arranging follow-up and support to clinical experts who are available to answer real-time clinical questions, including collaborating with the California Poison Control System in offering a 24/7 hotline for initiating and managing buprenorphine. This novel approach could be replicated by other states to expand their addiction medicine workforces by accessing opioid settlement dollars or enhanced Medicaid reimbursement. Poison Centers have existing 24/7 infrastructure available in all 50 US states that could be utilized to expand bedside clinician access to addiction expertise on a short and affordable timeline.
[..] It defies logic that a disease that causes 1 death every 5 minutes, with an annual economic cost exceeding $1 trillion and a 1-year mortality risk approaching 5% after an ED visit for a nonfatal overdose, does not demand a lifesaving campaign and quality audit monitoring and feedback. [..] While federal quality measures for opioid-related ED visits are lacking, states are taking action. A new law in Maryland effective January 1, 2025, requires each hospital to have protocols and the capacity to medically treat patients who present to the ED either after an opioid overdose or with an opioid-related condition. [..]
Questions from clinicians such as “Where will the patients follow up?” are common, even in light of pathways embedded into the electronic health record. The answer is simply “Just get them started!” Challenges to treatment access are frequently insurmountable during the chaos of addiction. Thus, prompt ED buprenorphine initiation has value even if follow-up is tenuous. Each dose of buprenorphine increases protection from an opioid overdose. For those presenting after opioid overdose, the subsequent 2 days are the highest-risk period for recurrent overdose, a critical window in which buprenorphine initiation could be lifesaving. Dekker et al also note that by 2020, 25% of second buprenorphine prescriptions were also from emergency clinicians, demonstrating emergency medicine’s willingness to act as an extended bridge to care.
Newer roadblocks have emerged from emergency clinicians lamenting the rise in fentanyl use precluding buprenorphine inductions and perseverating on the potential complication of precipitated withdrawal, a rapid onset of severe withdrawal symptoms caused by the partial opioid agonism of buprenorphine. This reluctance has limited the use of effective induction strategies. [..] While buprenorphine is safe in the era of fentanyl, it is also true that ED practice has been modified in recent years. These include offering more buprenorphine if a patient’s withdrawal symptoms increase or do not improve, in addition to offering an array of ancillary medications treating specific symptoms readily available in the ED setting. [..] If we are not using buprenorphine whenever feasible, we eliminate 1 of the 2 powerful evidence-based options for opioid addiction. Having real-time availability to experts in buprenorphine induction through technical assistance programs and poison centers could substantially help allay fears and improve adoption.
Overall, the good news is that the study by Dekker et al provides substantial evidence that with adequate state investments, EDs can play a crucial role for patients with opioid addiction—being available as a safety net 24 hours a day, 365 days a year, and providing pivotal steps in the cascade of care. California provides a model and blueprint for other states to follow for both urban and rural areas as we continue to fight this epidemic.”
Full editorial, G D’Onofrio, JB Cole and J Perrone, JAMA, 2025.2.19