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Legislative Updates:

Consolidated Appropriations Act of 2023 – Public Law No. 117-328 effective 12/29/2022 – Section 1262, Mainstreaming Addiction Treatment Act (MAT Act)
Any prescriber with a DEA license can prescribe buprenorphine for OUD

Elimination X waiver

STOP Act of 2022
Maryland – any patient with an overdose must be offered free naloxone from the hospital

Required naloxone

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Patient selection:

Patients with opioid use disorder (dependent on opioids)

Patients motivated to enter treatment/wanting medication-based treatment

Patient has no contraindications: methadone within 48-72h, true allergy to component

Patients in clinical withdrawal in the ED? COWS score > 8

ED Initiation

Patients not in clinical withdrawal in the ED? COWS <8

Take home initiation

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Orderset updates

Recommendation of ACEP/ASAM for ED treatment if “moderate/severe OUD”
Precipitated withdrawal more common with lower doses; DC/MD drug supply predominantly fentanyl (97%)

Initial buprenorphine dose 4mg/1mg 🡪 8mg/2mg

Max dose day 1 increased to 32mg buprenorphine

Rapid repeat buprenorphine dosing to 32mg
If refractory, consider low dose ketamine + adjuncts

Precipitated withdrawal management

Bupe dosing:

ACEP/ASAM bupe tool: https://www.acep.org/patient-care/bupe/

Strayer, R. J., Hawk, K., Hayes, B. D., Herring, A. A., Ketcham, E., LaPietra, A. M., Lynch, J. J., Motov, S., Repanshek, Z., Weiner, S. G., & Nelson, L. S. (2020). Management of Opioid Use Disorder in the Emergency Department: A White Paper Prepared for the American Academy of Emergency Medicine. Journal of Emergency Medicine, 58(3), 522-546. https://doi.org/10.1016/j.jemermed.2019.12.034

Herring AA, Vosooghi AA, Luftig J, et al. High-Dose Buprenorphine Induction in the Emergency Department for Treatment of Opioid Use Disorder. JAMA Netw Open. 2021;4(7):e2117128. doi:10.1001/jamanetworkopen.2021.17128

Spadaro, A, Faude, S, Perrone, J, et al. Precipitated opioid withdrawal after buprenorphine administration in patients presenting to the emergency department: A case series. JACEP Open. 2023; 4:e12880. https://doi.org/10.1002/emp2.12880

Rationale for management of PW with buprenorphine:

Herring, A. A., Perrone, J., & Nelson, L. S. (2019). Managing Opioid Withdrawal in the Emergency Department With Buprenorphine. Annals of Emergency Medicine, 73(5), 481-487. https://doi.org/10.1016/j.annemergmed.2018.11.032

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Orderset updates:

Buprenorphine prescription:

For patients initiated in the ED, OR for home initiation

Take-home adjuncts
Take-home naloxone for all patients
Follow up instructions + connection to treatment (if possible)

Discharge needs:

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Take Home Initiation

For patients not in withdrawal in the emergency department, but interested in buprenorphine, it is appropriate to start medication unsupervised at home.

Take home initiation orders include instructions for patients to assess the severity of withdrawal at home, and start medication accordingly

Prescription within orderset includes default instructions for take home initiation (can be modified/increased if patient is loaded in the department)

Prescribe enough days to get to treatment - on weekends, at least three days; if PRCs can get directly to treatment, may not need prescription

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FAQ

Does not require peer recovery coach intervention (nights/weekends)

Buprenorphine/naloxone 8mg/2mg in stock in pyxis, but if patient wants to use buprenorphine without naloxone, that’s okay (pharmacy has it)

Site specific follow up instructions for each Maryland site are available (search buprenorphine in depart process)

Provider support: Laura Haselden (Teams) or cell: 864-609-7398

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