Toolkit: Medication-Assisted Recovery/Treatment For Opioid Use Disorder (OUD)

Community: Hospital Emergency Department
Medication: Buprenorphine

ED MAR Intake and Assessment

Watch an experienced IL provider describe the intake and assessment protocols and patient materials that are used where he works.

See a workflow for smaller emergency department.Back to larger emergency department.

Hospital Emergency Department
Intake & Assessment

Triage Nurse

Assess patient’s chief complaint and perform a NIDA Quick Screen

non-acute complication, positive screen

acute complication linked to substance abuse

Social Worker

Assess substance use using AUDIT and/or DAST-10

MAR Provider / Nurse

Examine patient, evaluate for medical emergencies, and decide if hospital admission required

if high DAST-10

if not admitted

MAR Provider / Nurse

Assess withdrawal with COWS and complete a UDS.
Use motivational interviewing to assess the patients’ goals related to substance use and readiness to change.
If patient is interested, begin buprenorphine initiation following the CA Bridge Hospital Quick Start

Hospital Emergency Department
Intake & Assessment

MAR Provider

Assess opioid use with the DAST-10 and consider if patient meets DSM-5 criteria for OUD.

MAR Provider

Use motivational interviewing to have patient consider starting buprenorphine. If patient is interested, assess readiness for first dose of buprenorphine using COWS.

MAR Provider

Begin buprenorphine initiation following the CA Bridge Hospital Quick Start.

ED MAR Initiation

Watch an experienced IL provider describe the initiation protocols and patient materials that are used where she works.

Hospital Emergency Department
Initiation

Connect with patient:

MAR Provider

If patient is agreeable to initiating buprenorphine, have an open discussion about the benefits and risks of buprenorphine, including prior experiences. Offer education and reassurance if any negative outcomes (e.g., precipitated withdrawal) had occurred previously. Remember that accurate diagnosis and treatment require trust, collaboration, and shared decision making.

Has patient received naloxone for an overdose within the past 2 hours?

Yes

No

Post-Naloxone
Initiation
If patient is awake, shows signs of withdrawal (i.e., COWS ≥ 4), and does not present any exclusion criteria (see protocol for full details), give first dose of 16 mg SL buprenorphine, educating patient (see video) on how to properly take it.

Is patient in withdrawal?
(i.e., COWS ≥ 8 and ≥ 2 objectives signs; see diagnosis tips).

Yes

No

Standard Dose Initiation
Give first dose of 16 mg SL buprenorphine (see dosing tips). Educate patient (see video) on how to properly take the SL buprenorphine to ensure strong absorption and response.

Low Dose Initiation
Document rationale for strategy
(e.g., “patient not in withdrawal and had bad prior experiences with standard dose initiation”).
Educate patient on low dose protocol (see ex.) and administer first doses of bup., full agonists, and adjuvants.
Prescribe medicines needed to complete low dose protocol and proceed to discharge when patient is stable.
Note: If patient is admitted to
hospital, document low dose protocol in chart to ensure patient continues and fully completes initiation schedule.

Wait 1 hour

Wait 1 hour

Have withdrawal symptoms improved? (e.g., COWS is less than before)

Yes

No

Precip. Withdrawal (rare)

If withdrawal symptoms
have not fully resolved, give second dose of 16 mg SL buprenorphine.
Otherwise, proceed directly to discharge.

Consider extent that withdrawal has been undertreated. Treat any other withdrawal state or underlying medical/psychiatric condition that may be contributing to the clinical picture.

Give second dose of 16 mg SL bup and 2 mg lorazepam IV and follow “Treatment of bup precipitated withdrawal” flowchart.

Discharge*
To improve long-term outcomes, if possible, use a warm handoff procedure to ensure patient receives close follow-up within 1-2 weeks. Prescribe at least a 2-week supply of 16-32 mg SL buprenorphine daily. (The X-waiver has been eliminated; any DEA practitioner can prescribe.) Ensure patient has access to appropriate harm reduction materials (especially intranasal naloxone) and knows how to use them. *Discuss option of long-acting injectable (LAI) buprenorphine if available in your hospital. If patient is agreeable, proceed with this protocol.

If at any point, you need assistance with initiating MOUD treatment or providing follow-up or ongoing care management for your patient, contact MAR-NOW or IllinoisDocAssist.

ED MAR Warm Handoff

Watch an experienced IL provider describe the warm handoff protocols and patient materials that are used where she works.

Hospital Emergency Department
Warm Handoff

During ED Initiation

Recovery Coach / Patient

When paged for bedside consult, use a handout to educate patient on how to take buprenorphine.


After second dose, return to determine if patient is amenable to continuing treatment.

Before Discharge

If possible, schedule next-day (or soonest) appointment at an in-system MAR clinic in patient’s neighborhood. If not possible, schedule next-day (or soonest) appointment at an out-of-system MAR clinic and obtain patient’s release of information.


Address barriers (travel, insurance, etc.) to attending after-care appointment.

Next Day

Recovery Coach

Remind patient of appointment. Check later to determine if patient attended and note in chart.

Patient / Outpatient MAR Provider

If no-show, attempt to reengage patient to attend an appointment.
Address barriers again.