Emergency Department–Initiated Buprenorphine/Naloxone Treatment for Opioid Dependence

Management of opioid use disorders: a national clinical practice guideline

“…• Health Canada exemption is not required to prescribe buprenorphine-naloxone in most provinces and territories (Appendix 1) • Lower risk of overdose due to partial agonist properties and ceiling effect for respiratory depression (in the absence of benzodiazepines or alcohol) 19,24,25 • Lower risk of public safety harms if diverted 26,27 • Milder adverse effect profile 22,23 • Easier to transition from buprenorphine-naloxone to methadone if treatment is unsuccessful 22,23 • Shorter time to achieve therapeutic dose (1-3 d) [28][29][30] • Lower risk of toxicity and drug-drug interactions 31 • Milder withdrawal symptoms when discontinuing treatment; may be a better option for individuals with lower-intensity opioid dependence (e.g., oral opioid dependence, infrequent or no injection use, short history of opioid use disorder), and individuals planning to taper off opioid agonist treatment in a relatively short period 22,23 • Optimal for rural and remote locations where access to care is limited, methadone prescribers are lacking, or daily witnessed ingestion at a pharmacy is not feasible • More flexible dosing schedules (e.g., alternate-day dosing, earlier provision of 1-to 2-week take-home prescriptions, and unobserved home inductions) support patient autonomy and can reduce costs [32][33][34][35] • Easier to adjust and retitrate following missed doses, owing to its partial agonist properties…”

Treatment of Opioid-Use Disorders

“…6,61,62 Initiating buprenorphine maintenance as soon as possible (e.g., while the patient is hospitalized or after an emergency department visit) can enhance efficacy. 64 Combining maintenance therapy with a cognitive behavioral approach might improve outcomes.…”

Screening, brief intervention and referral of emergency department patients with unhealthy drug use: efficacious or not?

“…Because of the profound neurobiological and behavioural changes that characterise severe use disorders, it is likely that more potent interventions combining behavioural approaches with ED initiation of pharmacotherapy will be needed to produce sustained abstinence. These interventions may include ED-initiated treatment such as buprenorphine for opioid dependence,2 or nicotine replacement therapies for tobacco dependence,1 with referral to either community substance treatment programmes or office-based practice.…”