Buprenorphine in the ED: Why Aren’t We Doing More?

Beverly Johnson
Jan 12
3 min read

The data is there. But the drive to implement is lacking.

tech using an emr system-electronic medical records - advanced practice partners

Emergency departments (EDs) are often ground zero in the opioid overdose crisis. Yet despite growing awareness of Medications for Opioid Use Disorder (MOUD) as the gold standard treatment for opioid use disorder (OUD), buprenorphine remains vastly underutilized in acute care settings where our patients need it the most.

The 72-Hour Rule

Many clinicians are still unaware that any provider with a DEA registration—even if they do not have a buprenorphine specific X-waiver (which is no longer required)—can administer buprenorphine for up to 72 hours under federal law. Known as the “72-hour rule” (21 CFR 1306.07(b)), this provision allows non-addiction-trained providers to:

• Administer (but not prescribe) buprenorphine or methadone,

• For up to three consecutive days,

• While arranging follow-up care.

This rule was designed precisely for emergency settings where patients may be in withdrawal or at high risk of overdose. Yet it’s frequently overlooked due to stigma, provider discomfort, or institutional inertia.

Why Buprenorphine in the ED Works

Research shows that initiating buprenorphine in the ED significantly increases treatment engagement and reduces opioid use and overdose risk. A landmark Yale study published in JAMA (2015) found that patients started on buprenorphine in the ED were twice as likely to be engaged in treatment at 30 days compared to those who received referral alone.

Despite this, many EDs still rely on outdated practices: discharging patients with only a list of treatment programs or instructions to “follow up.” We wouldn’t treat chest pain this way—"You have elevated troponins. Here is a list of cardiologists in the area. Good luck.” Why are we still doing it for opioid withdrawal?

3 Easy Ways Addiction Providers Can Support ED Buprenorphine Starts

Addiction psychiatrists and other SUD specialists have a key role in shifting this culture. Here are three low-lift ways to get started:

1. Create a Simple Buprenorphine Protocol for the ED

Many ED providers are willing to start buprenorphine-they just need a clear roadmap. Collaborate with your hospital or health system to develop a protocol that:

• Outlines buprenorphine dosing (e.g., 8–12 mg SL for withdrawal),

• Includes COWS assessment guidance,

• Provides pre-written progress notes or order sets.

Tip: Keep the protocol short and pocket-friendly like this SAMHSA one-pager, not a dissertation.

2. Set Up a Warm Handoff System

Help establish a referral loop that allows ED patients to be seen by local addiction providers within 24–72 hours. This could be:

• A daily addiction consults line (staffed even part-time),

• Reserved same day/next day ED follow-up slots at your outpatient MOUD clinic,

• A care navigator who follows up post-discharge.

Warm handoffs are crucial. Without them, ED-initiated treatment often ends at the door.

3. Offer Free Low-Stakes Training or Shadowing

Run a one-hour training for ED staff on buprenorphine use or invite them to shadow your clinic for a half-day. Many providers are hesitant simply because they’ve never seen buprenorphine induction in action.

Normalize it, demystify it, show them that it’s not rocket science, and make yourself available for consults—even informally.

Virginia’s SUD Bridge Program Models State-Level Innovation

One state making major progress with incorporating ED buprenorphine inductions is my home state of Virginia, where the Department of Medical Assistance Services (DMAS) and the Department of Health have partnered with local hospital systems to implement the SUD “Bridge to Treatment” program.

The program supports ED buprenorphine initiation by:

• Funding peer recovery specialists and care coordinators,

• Standardizing ED-to-treatment handoffs,

• Offering training and technical support across the state.

Hospitals participating in the initiative receive resources and structured support to launch or scale ED MOUD pathways. The result? More patients start recovery at the point of crisis—and fewer fall through the cracks.

We have the tools. We have the evidence. And we even have the legal authority under the 72-hour rule. What’s missing is implementation—and that’s where addiction specialists can lead. By simplifying protocols, building referral bridges, and empowering colleagues, we can turn the ED from an unwelcoming, revolving door into a launchpad for recovery.

-Lauren Grawert

TAGS: #laurengrawert #advancedpracticepartners #wisconsin #mentalwellness #2025 #health #oped #wisdom #hipaa #psychiatrists #pmhnp #therapists #psychology #medical