UMEM Educational Pearls

BACKGROUND:
Emergency Medical Services (EMS) systems, especially those within urban jurisdictions, struggle to effectively meet the needs of patients experiencing complications of substance use. The exceedingly high burden of disease, coupled with potentially life-threatening sequelae of substance use stresses EMS systems beyond capacity. The current paradigm of naloxone administration and subsequent refusal of care places patients at an increased risk of death and other complications such as aspiration. EMS agencies, in collaboration with area hospitals, public health experts, and addiction medicine specialists are devising novel mitigation strategies to reduce morbidity and mortality. “Leave behind” naloxone, peer outreach, and 911 diversion programs are part of a more over-arching strategy that links patients to longer term, definitive health care resources within the community. EMS-administered buprenorphine has emerged as a novel treatment modality for prehospital patients. This study examined outcomes of patients who were a) experiencing symptoms of opiate withdrawal and b) given buprenorphine by a credentialed EMS paramedic. Patients included in the buprenorphine cohort scored >5 on the clinical opiate withdrawal scale (COWS), regained “full decisional capacity” after being resuscitated from an overdose, and were > 18 years of age. The study excluded pregnant patients and those who took methadone within 48 hours prior to an EMS encounter. After consultation with an EMS physician, patients received 16 mg of sublingual buprenorphine. Paramedics could administer ondansetron and an additional 8 mg of buprenorphine for continued symptoms. Finally, the study cohort was matched to a similar group of patients who were treated by “non buprenorphine equipped” ambulance. Outcomes of interest included: rates of repeat overdose, likelihood of transport, and follow up with addiction medicine/substance use resources. The study was conducted in an urban EMS system with robust EMS physician oversight and advanced life support transport units.

RESULTS:
Patients receiving buprenorphine did not experience a reduction in repeat overdose. However, they were less likely to be transported. The buprenorphine cohort, predictably, was much more likely to be enrolled in a substance use treatment program within 30 days of the initial encounter. Paramedics spent more time on scene with the buprenorphine cohort.  Though far from a conclusive study, the manuscript adds to a growing body of literature that attests to the feasibility of paramedic administered buprenorphine.

BOTTOM LINE:
Though far from a conclusive study, buprenorphine administration by EMS paramedics is feasible. The increased linkage to care and decreased rates of transport will hopefully motivate EMS systems to consider novel strategies for harm reduction. The study authors opine that buprenorphine may “be a promising…link to long term recovery.”

References