Prehospital Buprenorphine
Deena Wasserman, MD and Anand Swaminathan, MD
- Naloxone rescue therapy is life-saving in opiate overdose but it is also just the first step in treating opiate use disorder.
- Patients treated with naloxone for an opiate overdose have a 1 in 10 chance of death within the next year.
- Cooper University Hospital in Camden, NJ has a comprehensive approach:
- 100% of ED physician staff have x-waivers (ie, they have US DEA legal prescribing status).
- Clinicians can link patients to follow up 24 hours a day, 7 days a week.
- Cooper EMS crews have become an extension of the ED
- This solves the problem that many patients with opiate overdoses don’t make it to the ED.
- Paramedics are trained to identify patients with opiate withdrawal who are eligible for buprenorphine.
- A buprenorphine command physician is available to approve a “bupe bundle”
- Initial dose: buprenorphine 16 mg sublingual
- Zofran 4 mg sublingual PRN
- Additional dose: buprenorphine 8 mg sublingual (if needed)
- The large buprenorphine dose was selected to overcome precipitated withdrawal by saturating receptors.
- Once withdrawal is adequately treated, the patient is given a card with an appointment for follow up the next day.
Related Segments
EM:RAP 2018 September: Strayerisms: Opioid Abuse and Buprenorphine
EM:RAP 2020 June: Strayerisms: Opiate Use Disorder Part 2
James H. - April 8, 2021 12:47 PM
Would be nice to have the protocol they used attached.
maranda s. - April 16, 2021 5:13 AM
So the x waiver is still required? It seems the HHS issued an exemption where it wasn't required 1/14/21 and then the decision was reversed 1/27 pending congressional approval.
https://www.emsworld.com/press-release/1225487/hhs-removes-x-waiver-requirement-buprenorphine
https://www.emra.org/emresident/article/x-waiver-update/
Erin M. - May 5, 2021 5:21 PM
Check again! X-waiver is back in place but only requires a declaration of intent to prescribe for those treating under 30 patients at one time.
https://www.federalregister.gov/documents/2021/04/28/2021-08961/practice-guidelines-for-the-administration-of-buprenorphine-for-treating-opioid-use-disorder
Anand S. - May 5, 2021 5:29 PM
Yes. This saga has gone back and forth. We'll have a piece up from Reuben Strayer later this week with an update of where we stand today.