EMU 365: Expanding Our Scope – ED Initiated Buprenorphine

This EMU365 video features Dr. Reuben Strayer, who discusses incorporating ED initiated buprenorphine into our practice and how we can improve morbidity and mortality in patients with opioid use disorder in the era of the opioid epidemic. 

Key message: Abstinence (detox) and counselling alone are not effective for opioid addiction. The appropriate treatment is opioid substitution using Medication Assisted Treatment (MAT).


  • Partial opioid agonist = ceiling effect: much safer, less euphoriant
  • Higher receptor affinity than almost any other opioid, thus will precipitate withdrawal if patient is not already in withdrawal
  • Less abuse prone and blocks more abuse prone opioids 
  • However, when used alone, can be abuse prone, but when combined with naloxone, it is not 

Buprenorphine + naloxone = suboxone

  • Naloxone additive is inert unless injected, its purpose to is to prevent IV abuse of buprenorphine

Buprenorphine initiation in the ED:

  1. Patient with opioid use disorder is in withdrawal (COWS > 8)
  2. Buprenorphine initiation 4-8mg SL in ED. Unless patient feels 100% better and has follow up 12-24hrs, top up with additional 8 or 16mg to prolong the therapeutic window (goal > 16mg)
  3. Refer to comprehensive outpatient addiction care with ideally with buprenorphine Rx

Opioid Use Disorder ED Scenarios

  • Active withdrawal (did not receive naloxone) – ED buprenorphine
  • Opioid intoxicated – home initiation 
  • Sober (not intoxicated, not in withdrawal, but will be) – home/ED/observation
  • “Detox” (withdrawal symptoms over) – ED buprenorphine
  • Naloxone-precipitated withdrawal – we don’t know yet, start with non-agonists (haldol, midaz etc.) then reassess
  • Patient declines buprenorphine – do they misunderstand or are they not ready for recovery? Employ harm reduction strategies, open door policy

EM Cases Episode 116 Emergency Management of Opioid Misuse, Overdose and Withdrawal

Speaker Bio

Reuben Strayer, MD, FRCPC, FACEP, FAAEM was born on the shores of Lake Michigan but raised and schooled in Texas until emigrating to balmy Montreal for a residency in emergency medicine and now lives and works in New York City. His clinical areas of interest include airway management, analgesia, opioid misuse, procedural sedation, agitation, decision-making and error. His extra-clinical areas of interest include sweeping generalizations and jalapeño peppers. He is happily employed at Maimonides Medical Center in Brooklyn.

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