Rebellion in EM 2019: Suboxone for Opioid Addiction via Salil Bhandari, MD

Written by Salim Rezaie REBEL EM Medical Category: Toxicology

Background: The role of the ED physician in helping stop the opioid epidemic is three-fold: safe prescribing practices, beginning suboxone administration in the ED as part of an ED/Community Suboxone program, and providing Narcan prescriptions to at risk patients. Most ED physicians are not doing the latter two.

Rebellion in EM 2019: Suboxone for Opioid Addiction via Salil Bhandari, MD

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Suboxone for Opioid Addiction

Past treatments for opioid addiction do not work including addiction therapy, detox centers, methadone, and naltrexone

Critical Point #1 : Opioid addiction is not a moral failing but a chronic disease that needs medical assistance in order to treat, and Suboxone is the treatment

Suboxone is a combination of buprenorphine (a partial agonist at mu-opioid receptor that replacing opioids being abused) and naloxone (a mu-opioid antagonist only active if injected IV whose sole purpose is to prevent abuse)

Suboxone has a ceiling for its respiratory depression and euphoric effects

Suboxone should be initiated in the ED because that’s where the patients are!

Critical Point #2 : Suboxone MUST be initiated when patients are in mild to moderate withdrawal, otherwise it’s administration will precipitate a withdrawal.

You do not need an X-waiver to administer a dose of Suboxone in the ED for acute withdrawal, only to write a prescription for it

Critical Point #3 : After administration of suboxone in the ED patients MUST be referred to an outpatient community program that can continue prescribing suboxone to the patient

Patients taking suboxone have longer treatment retention and longer abstinence from opioid abuse

References:

To Obtain an X-Waiver: Provider’s Clinical Support System for Medication-Assisted Treatment (PCSS-MAT) [Link is HERE] D’Onofrio G et al. Emergency Department–Initiated Buprenorphine/Naloxone Treatment for Opioid Dependence: A Randomized Clinical Trial. JAMA 2015. PMID: 28194688 Larochelle MR et al. Medication for Opioid Use Disorder After Nonfatal Opioid Overdose and Association With Mortality: A Cohort Study. Ann Intern Med 2018. PMID: 29913516 Herring AA et al. Managing Opioid Withdrawal in the Emergency Department with Buprenorphine. Annals of Emergency Medicine 2019. PMID: 30616926

Post Peer Reviewed By: Salim R. Rezaie, MD (Twitter: @srrezaie)