Initiating Buprenorphine-based MAT in Emergency Departments

Why this strategy works

Even if a patient in the emergency department is very eager to begin MAT, receiving a referral and possibly waiting several days to begin care greatly decreases the likelihood that this patient will successfully engage in care. Providing an initial dose of buprenorphine in the emergency department eliminates these delays in care and allows the patient to begin experiencing the benefits of MAT immediately. Subsequent daily doses provided by the hospital (either by prescription or by supervised consumption at the hospital pharmacy) serve as a "bridge," providing the patient with care on a temporary basis, if necessary, while a referral and "warm hand off" to physician who can continue to provide MAT is carried out,  

Initiating buprenorphine-based MAT in emergency departments works best when: 

There is no broadly accepted "best practice" for initiating patients onto buprenorphine-based MAT in an emergency department. This intervention is very new, and researchers are still studying how best to serve patients' needs and assist them in engaging with care. Patients who are initiate in the emergency department are very likely there because they have experienced an overdose crisis. It can be expected that such an experience may change the meaning of treatment for these patients, and the value of treatment may change in an inconsistent or counter-intuitive way over time,

What we do know, however, is that each instance of engagement in MAT, even if the patient eventually drops out of care, predicts higher success the next time treatment is sought. Furthermore, providing "bridging" doses of MAT medications to individuals seeking treatment greatly improves patient engagement in MAT care during treatment initiation--a key moment for those with opioid use disorder, when maintaining trust and stability is of utmost importance.

• A 2010 study conducted in a location with very long wait lists (6 months or more) for MAT provided those who were seeking treatment through a personal physician or licensed opioid treatment program with immediate access to buprenorphine via prescription while they waited for a slot in a formal treatment program. Compared to those who were not offered this medication immediately, these individuals reported significant reductions in illicit opioid cravings, even before they began wrap-around treatment. The medication adherence rate was 99%, indicating almost no medication diversion.

• Yale University Hospital conducted a randomized controlled trial to test the effect of initiating patients on buprenorphine in the emergency department and then continuing that MAT in primary care. Two months later, those patients who received buprenorphine prior to a referral for MAT where more likely to be engaged in care and had lower rates of illicit opioid use. Six months later, the study's findings were less encouraging, which indicates that patients initiated onto MAT in the emergency department may need additional supports to remain engaged in care. The hospital now employs patient navigators and counselors to support patients who may be struggling to maintain their treatment.