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Study: ER buprenorphine induction found to be effective even when fentanyl is present

Updated: Jun 5, 2023

Buprenorphine initiation in the ER is an effective tool for the treatment of opioid use disorders (OUDs) that include the use of fentanyl, a new clinical trial has found.

The study was published in JAMA Network Open and found that less than 1% of people with OUDs who used fentanyl experienced withdrawal after starting buprenorphine. The study involved 1,200 adult patients with untreated OUD and was funded by the Helping to End Addiction Long-term Initiative, or NIH HEAL Initiative®—a trans-agency effort to speed scientific solutions to stem the national opioid crisis.

“The study enhances the evidence we know about ED buprenorphine induction, and could be a game changer, particularly for vulnerable populations,” shared Dr. Gail 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’s findings countered concerns among some doctors that buprenorphine use would lead to unacceptable levels of precipitated withdrawal symptoms among users of fentanyl, which is a very strong and deadly opioid. These symptoms, which are brought on by OUD treatment medications, can include severe muscle aches, nausea and vomiting, and excessive diarrhea and cramping soon after taking buprenorphine. Because of the potential for these symptoms to occur, ER doctors are sometimes hesitant to use buprenorphine, lest the patient decline buprenorphine treatment after experiencing them.

Twenty-eight emergency departments participated in the clinical trial, which ran from June 30, 2020, to October 26, 2022. The study examined patients who had opioid-positive and methadone-negative urine screenings, and a Clinical Opiate Withdrawal Scale (COWS) score of 4 or higher. A patient was considered to have experienced precipitated withdrawal if his or her COWS score climbed at least five points on the scale, requiring additional buprenorphine and other medications. A total of nine participants, all of whom had taken fentanyl, met these criteria: 0.76% of the study’s overall participants, and 0.98% of those known to have taken fentanyl.

The study’s authors concluded that buprenorphine induction in the ER is safe, effective, and critical.

They concluded that “continued access to buprenorphine for opioid use disorder treatment is essential given the ongoing overdose crisis.”

"Patients who are initiated on buprenorphine at the time of the ED visit are more likely to be in treatment at 30 days. Administering or providing prescriptions/medications eliminates many challenges that the patient faces to initiating treatment. Dispensing naloxone for harm reduction is also essential," stated D'Onofrino


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