Implementation Barriers of Prehospital Buprenorphine Administration Programs in the United States: A Scoping Review

Prehospital buprenorphine administration programs (PBAPs) have spread throughout the United States (U.S.) with limited information on their locations or barriers to implementation, posing challenges to emergency medical services (EMS) systems adopting this clinical care model. This scoping review identifies where current PBAPs operate and summarizes commonly reported barriers to PBAP implementation.

State Offices of EMS were contacted by phone and email and asked if PBAPs operated within the state. After three failed attempts, representative physicians from remaining states were queried through the National Association of EMS Physicians' state membership. Four databases identified PBAPs from manuscripts, popular media, and conference proceedings from each database's inception to 8/25/2024. Programs were included if EMS clinicians administered buprenorphine. Data extraction from academic manuscripts, popular media, and conference proceedings included PBAP location, personnel, protocols, and implementation barriers. Results were reported utilizing Preferred Reporting Items for Systematic Reviews and Meta Analyses extension for Scoping Reviews.

Nineteen states and Washington D.C. reported at least one PBAP, 28 reported none, 3 were pending implementation. Of 977 identified titles, 17 met inclusion criteria. Seven media articles, 4 conference presentations, 3 cohort studies, 2 case series, and 1 scoping review yielded data on 13 unique PBAPs within 8 states. Most PBAPs delivered buprenorphine via 9-1-1 paramedics (61.5%) during an EMS response, or by community paramedics (46.1%) within 24-48 h of an EMS response to a patient who experienced an overdose. Five (33.3%) PBAPs reported at least one patient-related barrier to PBAP implementation, including reasons buprenorphine was not administered, lack of treatment access, and patient loss of follow-up. Four programs reported operational-level barriers, including in-person restrictions due to COVID-19, siloing of outpatient services, lack of outpatient service options, inconsistent education of PBAP staff, inconsistent application of PBAP protocols by EMS clinicians, high turnover, and difficulty procuring buprenorphine.

Whereas 19 states in the U.S. and Washington D.C. reported having at least one PBAP, few are reported in literature, and very few report barriers to PBAP implementation. Developing consensus on metrics assessing PBAP implementation is necessary to inform EMS agencies implementing these novel programs throughout the U.S.