High-dose buprenorphine in EDs may improve patient outcomes

The administration of high-dose buprenorphine therapy in hospital emergency departments (ED) may safely and rapidly diminish withdrawal symptoms and sustain craving suppression in people with opioid use disorder, improving their likelihood of accessing follow-up treatment, according to a study co-authored by Yale’s Gail D’Onofrio.

Buprenorphine is a medication approved by the U.S. Food and Drug Administration to treat opioid use disorder. Giving lower doses of the medication is the current standard of care. The study found, however, that giving higher doses of buprenorphine in EDs may provide a longer period of relief to people after they are discharged, which may help them navigate barriers to access to follow-up care before they experience withdrawal symptoms.

The findings were reported July 15 in JAMA Network Open.

“The study enhances the evidence we know about ED buprenorphine disorder, and could be a game changer, particularly for vulnerable populations,” said D’Onofrio, the Albert E. Kent Professor of Emergency Medicine, professor of epidemiology, and the inaugural chair of the Department of Emergency Medicine at the Yale School of Medicine.

The study was supported by the National Institutes of Health’s National Institute on Drug Abuse (NIDA).

For the study, the researchers analyzed data from electronic health records documenting 579 emergency department visits made in 2018 by 391 adults with opioid use disorder at Alameda Health System-Highland Hospital in Oakland, California. Many of the patients were from vulnerable populations: 23% experienced homelessness and 41% had a psychiatric disorder.

In 63% of cases, the clinicians administered more than the standard upper limit of 12 milligrams of buprenorphine during the ED visit, and in 23% of cases, patients were given 28 milligrams or more. The study found that higher doses of buprenorphine are safe and that none of the patients reported possible side effects of the medication, such as respiratory problems or drowsiness.

D’Onofrio and Yale colleagues have published earlier studies on ED-initiated buprenorphine. She is also part of Yale team of substance-use disorder researchers that has advocated for wider use of the medication in emergency departments. While studies have shown that initiating buprenorphine in EDs improves patients’ chances of seeking follow-up treatment and is cost effective, there are barriers to the medication’s use: ED clinicians can dispense buprenorphine, but there are strict controls on prescribing the medication, and clinicians must be certified to provide a prescription upon discharge.

In the new study, D’Onofrio and the other researchers note that the increased potency of illicit drugs and delays in accessing follow-up care make the findings especially relevant.

In 2019, D’Onofrio and David Fiellin, director of the Yale Program in Addiction Medicine, won a $25.5 million grant to develop programs for opioid treatment using buprenorphine at EDs in 30 urban and community hospitals around the country as part of the National Institutes of Health HEAL Initiative on Opioids.

“Opioid use disorder has become pervasive in our society, placing emergency departments on the frontlines of treating those with substance-use-related health problems, such as withdrawal,” said Nora D. Volkow, director of the National Institute on Drug Abuse and co-author of the new study. “Providing buprenorphine in emergency departments presents an opportunity to expand access to treatment, especially for underserved populations, by providing urgent care with a bridge to outpatient services that may ultimately improve long-term outcomes.”

Changes to expand physicians’ ability to prescribe buprenorphine are under review in the U.S. Department of Health and Human Services.

The research was supported by NIDA’s Clinical Trials Network. Andrew Herring of the Highland Hospital Department of Emergency Medicine in Oakland was the lead author of the study.