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.
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
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
Resources
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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
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.
Resources
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