An emergency department provider is a jack of all trades. The ED is open 24/7, and we’re equally as prepared to stop a hemorrhage, deliver a baby, evaluate a mental health crisis or treat a heart attack as we are to refill blood pressure medication or pull an insect out of an ear canal.
Our primary role is triage—rapid stabilization and short-term care for anything and everything. For many patients, we are the only accessible source of health care, and we are ethically and legally bound to offer equitable care to all. We recognize our role as an entry point to outpatient care for nearly every medical condition—except for substance use disorder.
Many overdose patients we treat in the ED request methadone, often because they’re struggling with barriers at their programs. But in four years as an ED doctor, only a handful of patients have asked me about buprenorphine without my mentioning it first.
If an ED patient admitted for overdose is interested in bupe and isn’t allergic to it, that’s pretty much all they need to be eligible for us to initiate it on the spot. In my experience, the majority of the people we treat for overdose in the ED are good candidates for bupe, but they often aren’t getting it, even though it’s the standard of care.
Colleagues sometimes confess that they don’t bring up bupe with OD patients because they just aren’t confident.
Buprenorphine can be rapidly and safely initiated in the ED, easing withdrawal for those experiencing it and providing a safeguard against future overdoses. Bupe is among the safer medications dispensed in the ED, and ED providers are among the only ones who don’t need an X-waiver to dispense bupe to people with OUD. But we continue to undertreat.
The continued existence of the X-waiver, a unique regulation that only applies to bupe, perpetuates the stigma that makes so many practitioners avoid this medication. The X-waiver falsely suggests that buprenorphine is uniquely dangerous or in need of special regulation relative to other medications. It also creates legal uncertainty: Providers who think they aren’t eligible to prescribe bupe are unlikely to learn how to prescribe it safely. Colleagues sometimes confess that they don’t bring up bupe with OD patients because they just aren’t confident about how to prescribe it or advise on its use.
For the 20 years bupe has been an approved opioid use disorder (OUD) treatment, ED providers have been able to dispense it without actually writing a prescription, and thus without an X-waiver—but only a three-day supply, dispensed one day at a time. This means that to get three days’ worth of bupe, patients have to visit the ED on three different days, which is inconvenient and unsustainable for patients and providers alike.
As of March, providers can request DEA-exemption from the one-day-at-a-time restriction in order to dispense all three days’ worth at once. Hospital administrators can also submit a blanket request and not only save individual providers the trouble, but likely retain many who were ambivalent about pursuing it on their own. Making it easier to dispense this medication, and lowering legal barriers around prescription, are essential to easing the path to consistent use.
An ED provider already knows how to recognize withdrawal and how to help alleviate it—they can also learn how to avoid precipitating it. The concept should already be familiar. When patients present with overdose, we give just enough naloxone to get them breathing on their own, stopping short of a full reversal. We understand that the goal is not detox, nor punishment; the goal is alive.
ED providers can differentiate between patients at higher versus lower risk for overdosing again after they leave. With the former, we can start a conversation about bupe by asking if they’ve been on medications for OUD before, and assuring them we don’t have to give them a formal diagnosis of OUD in their records. If they do want to leave the ED with a few days’ worth of bupe, we should also make sure they leave with a suitable induction protocol and medications to help manage other symptoms. What we struggle to equip them with, however, is linkage to an X-waivered outpatient provider who will continue their care.
For other medical problems, we often give patients a 30-day supply of the medications they need, and the number of a nearby clinic that accepts patients that treat their condition and accepts their insurance. But with bupe, it’s not so simple. Starting a patient on bupe with no way to refill it can raise someone’s mortality risk, should they lose access to bupe and resume other opioid use. Without follow-up, we could be causing more harm than we reduce.
Critical care undeniably includes bupe—and we must not use the failings of the health care system as a cover.
Even in states with expanded Medicaid, where bupe is more accessible, prescribing it still involves restrictions, like prior authorizations and limits on length of use under some plans. The lack of outpatient providers is, in and of itself, why some ED providers don’t offer bupe. Patients who want to continue treatment but don’t have access to an outpatient source will return to the ED again and again. Some hospital administrators will even warn us against dispensing bupe, claiming that doing so is inviting crowds of sick patients to come back to the ED for their continued care: “We don’t want this to turn into a methadone clinic.”
It’s true that administering services meant for outpatient providers further strains our ability to provide other critical care. But critical care undeniably includes bupe—and we must not use the failings of the health care system as a cover.
Many hospitals have begun employing peer counselors to engage patients in these discussions and bridge the transition to outpatient care. EDs need to hire people with lived experience in order to improve patient care, and educate staff who aren’t already familiar with bupe. Of all the things we can do in the ED to keep people alive and healthy, offering bupe is one of the quickest, safest and most effective. How can we not?
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