As opioid overdose rates continue to rise, so have emergency medical services (EMS) encounters for suspected opioid overdose. Typically, EMS arrives on the scene of a suspected overdose, administers naloxone, provides any necessary advanced life support, and offers transport to the hospital Emergency Department (ED). Although not routinely happening in all EDs, the best practice is for the ED to offer the patient the option to initiate buprenorphine, withdrawal symptom medication management, and linkage to outpatient services. Buprenorphine treatment for opioid use disorder is highly effective but remains underused among overdose survivors.[i] In addition, many patients who receive EMS care for opioid overdose decline hospital transport – meaning there is no opportunity for ED-administered buprenorphine or linkage to outpatient addiction treatment. One recent study found 42 percent of all people who received naloxone in the field refused hospital transport. The same study found that those who declined hospital transport were at increased risk of subsequent non-fatal overdose requiring EMS intervention.[ii]
Recognizing EMS encounters as a potential lost opportunity for treatment initiation among individuals at high risk of subsequent opioid overdose, EMS in multiple cities in the United States have begun piloting field-based buprenorphine initiation. Cooper University Health Care provides EMS for Camden, New Jersey, and has been a pioneer in this work, developing the Buprenorphine Field Initiation of Rescue Treatment by EMS program. The EMS protocol in Camden is described in the graphic below; more information can be found here.
EMS receives call for suspected overdose.
EMS arrives on scene and administers naloxone.
Patents with a naloxone-induced clinical opiate withdrawal scale (COWS) score of >7 are eligible for buprenorphine.*
Paramedics discuss case with EMS physician, and if approved, paramedics offer buprenorphine 16mg and patient gives consent.
Paramedics monitor patient for change in withdrawal symptoms; they can administer another 8mg if patient has continued withdrawal symptoms after initial dose.
Patients administered buprenorphine receive a substance use disorder clinic appointment for the same day or next business day.
*Patients are not eligible if they have ingested methadone in the prior 48 hours or are pregnant, younger than 18 years old, or unwilling to provide their name or date of birth
An evaluation of the Camden Buprenorphine Field Initiation of Rescue Treatment by EMS program from August 2019–November 2020 reported that 1230 patients received care for suspected overdose from a buprenorphine equipped ambulance. Ninety-seven (7.8 percent) patients were administered buprenorphine. The program evaluation compared individuals who received care from a buprenorphine-equipped ambulance, and therefore could initiate buprenorphine in the field, with a case-matched sample who received care from an ambulance that had not yet implemented the buprenorphine protocol. Their key findings were:
- Patients who received buprenorphine in the field experienced a decrease in withdrawal symptoms, with an average decrease of COWS score from 9.27 to 3.16.
- Patients who received buprenorphine had greater odds of engaging in opioid use disorder treatment within 30 days of the EMS encounter, with 42 percent attending a clinic appointment.
- Paramedics on buprenorphine-equipped ambulances spent approximately 6 minutes longer on-scene.
- Receiving care from a buprenorphine-equipped ambulance did not decrease repeat overdose compared to a non-buprenorphine equipped ambulance.[iii]
As overdose rates continue to rise in the United States, we look for opportunities for service engagement among individuals who are at risk for overdose. EMS-administered buprenorphine is an example of an innovative practice aiming to offer individuals immediate initiation of a life-saving treatment with linkage to ongoing care. Further research is needed to better understand how to increase acceptance of this service, improve linkage rates, and increase retention in treatment.
Sources:
[i] Larochelle, M.R., Stopka, T.J., Xuan, Z., Liebschutz, J.M., & Walley, AY. (2019). Medication for opioid use disorder after nonfatal opioid overdose and mortality. Annals of Internal Medicine. 170(6), 430-431. doi: 10.7326/L18-0685. PMID: 30884508.
[ii] Zozula, A., Neth, M.R., Hogan, A.N., Stolz, U., & McMullan J. (2022). Non-transport after prehospital naloxone administration is associated with higher risk of subsequent non-fatal overdose. Prehospital Emergency Care Journal. 26(2), 272-279. doi: 10.1080/10903127.2021.1884324. Epub 2021 Feb 26. PMID: 33535012.
[iii] Carroll, G., Solomon, K.T., Heil, J., Saloner, B., Stuart, E.A., Patel, E.Y., Greifer, N., Salzman, M., Murphy, E., Baston, K., & Haroz, R. (2023). Impact of administering buprenorphine to overdose survivors using emergency medical services. Annals of Internal Medicine. 81(2), 165-175. doi: 10.1016/j.annemergmed.2022.07.006. Epub 2022 Oct 1. PMID: 36192278.