A July 2021 news release by the National Institute on Drug Abuse (NIDA) announced the results of a study that showed significant benefits were received by people with opioid use disorder experiencing opioid withdrawal symptoms when emergency department staff administered high-dose buprenorphine upon discharge from the hospital.
This study, which was supported by NIDA and the National Institutes of Health’s “Helping to End Addiction Long-term” (HEAL) Initiative, sprang forward from the recognition that lower doses of buprenorphine, an FDA-approved prescription drug, are currently widely used for treating opioid use disorder. The researchers’ premise was that higher doses of buprenorphine may offer a valuable extension of withdrawal relief to people after being discharged from the emergency department, thereby helping them “navigate barriers to obtaining medications, as well as accessing care for the treatment of opioid use disorder.”
Results of the study found high-dose buprenorphine therapy, provided under emergency department care, is safe and well tolerated in people with opioid use disorder experiencing opioid withdrawal symptoms.
Nora D. Volkow, M.D., director of NIDA, observed, “Emergency departments are at the front lines of treating people with opioid use disorder and helping them overcome barriers to recovery such as withdrawal. Providing buprenorphine in emergency departments presents an opportunity to expand access to treatment, especially for underserved populations, by supplementing urgent care with a bridge to outpatient services that may ultimately improve long-term outcomes.”
The research team noted some emergency departments already use higher doses of buprenorphine for the treatment of withdrawal and opioid use disorder—especially given the rise in opioid use disorder-related deaths, the escalating potency of opioids in the illicit drug market, and the commonly encountered delays in access to follow-up care. However, this practice was not deemed widespread and had not been evaluated earlier.
Basing their study on a retrospective chart review, the research team analyzed the 2018 data from electronic health records of nearly 400 adults making approximately 600 emergency department visits to Alameda Health System‒Highland Hospital in Oakland, California. Many of the patients were from vulnerable populations, and 44% of patients were Black, with 15% being Hispanic or Latino.
In nearly two-thirds of cases, the emergency department clinicians gave patients more than the standard upper limit of 12 mg of sublingual buprenorphine during emergency department induction; and in one fourth of cases, patients were given 28 mg or more. Researchers found these higher doses of buprenorphine were both safe and tolerable, and among those given the higher doses, there were no reports of respiratory problems or drowsiness – which are possible side effects of the medication.
As previously reported by NIDA, studies have shown that initiating buprenorphine in emergency departments improves engagement in treatment and is cost-effective – however, “barriers to the medication’s use persist. At the time of the study, there were strict controls on buprenorphine prescribing. While clinicians could dispense the medication in the emergency department, only those who had fulfilled the federal certification requirements related to training and ancillary services needed to obtain a buprenorphine prescribing waiver could provide a prescription upon discharge.”
The July 2021 study explained that those suffering from opioid use disorder who had been discharged without a prescription for buprenorphine could more readily experience a return of withdrawal symptoms—and corresponding risk of relapse—before they had a sufficient opportunity to access follow-up care. (It should be noted, recent revisions to federal prescribing guidelines have, when specific conditions have been met, make it easier for clinicians to prescribe buprenorphine.)
The research study’s team leader, Andrew A. Herring, M.D., of Highland Hospital Department of Emergency Medicine, stated, “Once discharged, many people have difficulty linking to follow-up medical care. Adjusting the timing and dosage of buprenorphine in the emergency department, along with resources and counseling aimed at facilitating the transition to outpatient services, may provide the momentum needed to access continuing care.”
The study’s author, Gail D’Onofrio, M.D., of Yale University, concluded, “This study enhances the evidence we know about emergency-department buprenorphine induction, and could be a gamechanger, particularly for vulnerable populations who would likely benefit from a rapid induction at the time of the visit.”