Feasibility of rapid low dose buprenorphine initiation in an emergency department observation unit

Emergency Department Observation Units (EDOUs) may provide a structured setting to initiate buprenorphine for patients with Opioid Use Disorder (OUD) who are not in sufficient withdrawal for standard induction.

To evaluate the feasibility of a 72-h rapid low-dose buprenorphine initiation (RLDBI) protocol in an EDOU supervised by emergency physicians.

We conducted an observational pilot study at a large urban hospital between July 2023 and June 2024. Adult ED patients with OUD who agreed to buprenorphine treatment but were in mild or no withdrawal were enrolled into an EDOU RLDBI pathway. The primary outcome was feasibility, defined as a treatment success rate > 50 %, with success being discharge on ≥8 mg of sublingual buprenorphine or receipt of extended-release buprenorphine (BUP-XR). Secondary outcomes included 30-day outpatient follow-up and 90-day opioid-related ED recidivism. Analyses were descriptive, as this pilot was not powered for hypothesis testing.

Fifty-five patients were enrolled. Thirty-three (60 %, 95 % CI: 47-72 %) achieved treatment success, exceeding the prespecified feasibility threshold. Among patients who succeeded, 39 % attended outpatient follow-up within 30 days, compared to 24 % in the overall cohort. Opioid-related ED recidivism within 90 days occurred in 40 % overall, with a lower proportion among those successfully initiated.

This pilot study suggests that a 72-h EDOU-based RLDBI pathway is feasible for initiating buprenorphine in patients not suitable for macroinduction. Trends in follow-up and recidivism should be interpreted cautiously, but these preliminary findings support further evaluation of EDOU-based RLDBI in the emergency care setting.