Managing opioid withdrawal in the ED: Best practices for buprenorphine induction

Opioid use disorder (OUD) is a pervasive, undertreated condition best managed with medications. Buprenorphine is a partial agonist with high affinity for the mu opioid receptor. It is particularly effective in treating OUD, resulting in reduced opioid use, risk of overdose, and all-cause mortality. Buprenorphine induction in the emergency department (ED) is an evidence-based practice for initiating OUD treatment while managing opioid withdrawal symptoms. Current guidelines from the Substance Abuse and Mental Health Services Administration recommend following a standard-dose induction regimen implemented over 2 days. However, variability exists among ED-initiated protocols in terms of timing, dose, duration, and formulation. ED providers should use their clinical judgment when approaching buprenorphine induction for opioid withdrawal management and OUD treatment. This article reviews current evidence and practical strategies for initiating buprenorphine in the ED, with an emphasis on patient evaluation, buprenorphine dosing, and continuity of care.