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Yale Model of Emergency Department-Initiated Buprenorphine

A program model in a hospital in Connecticut that allows clinicians to initiate buprenorphine in the emergency department after opioid-related events and for people seeking treatment

Begun as a pilot in 2009 and now rolled out as standard of care, the Yale Model for the induction of buprenorphine in the emergency department shows promise as a vital interface to identify and initiate evidence-based treatment for opioid use disorder (OUD).

Upon presentation in the emergency room, those that are seeking treatment for OUD, screen positive for opioids, or are experiencing opioid-related events, such as a nonfatal overdose, opioid withdrawal, or infectious complications (e.g. HIV, Hepatitis C, abscesses), are assessed based on the DSM-V criteria for OUD and the COWS scale for opioid withdrawal.

If clinically indicated, buprenorphine will be initiated in the emergency department if the patient is in withdrawal, or the provider will prescribe buprenorphine and provide instructions for at-home induction for patients who are not in withdrawal. Each initiation path includes a short-term prescription for buprenorphine and a warm hand-off referral to a local buprenorphine provider within 48-72 hours.

There is also the presence of health promotions advocates (HPA) that help to motivate patients and connect them to community supports and providers. If an eligible patient does not want to begin treatment, HPAs will provide harm reduction strategies such as overdose education and naloxone distribution. A toolkit that helps other emergency departments implement this program model is available here. 

78% of patients in the buprenorphine group compared with 37% in the referral group and 45% in the brief intervention group were engaged in addiction treatment on the 30th day after randomization.

Continuum of Care
Treatment
Type of Evidence
Peer-reviewed
Replicated
Response Approach
Early Intervention
Medications for Opioid Use Disorder
Overdose prevention
Post-overdose response
Peer-reviewed Article
Emergency Department–Initiated Buprenorphine/Naloxone Treatment for Opioid Dependence: A Randomized Clinical Trial
Emergency Department-Initiated Buprenorphine for Opioid Dependence with Continuation in Primary Care: Outcomes During and After Intervention
Cost Effectiveness of Emergency Department-Initiated Treatment for Opioid Dependence
Related Resources
Guidelines for Medication for Addiction Treatment for Opioid Use Disorder within the Emergency Department
Hospitals’ Role in Addressing the Opioid Crisis: Buprenorphine in the Emergency Department
Emergency department screening and interventions for substance use disorders
Emergency Discharge Protocols for Patients with Substance Use Disorders and Opioid Overdoses in Maryland’s Hospitals
Medication-Assisted Treatment With Buprenorphine: Assessing the Evidence
Planning and Designing the Improving Addiction Care Team (IMPACT) for Hospitalized Adults with Substance Use Disorder
A Novel Social Work Approach to Emergency Department Buprenorphine Induction and Warm Hand-Off to Community Providers
A Scoping Review of Post Opioid-Overdose Interventions

Evidence of Program Effectiveness

In a randomized controlled study of three groups, "78% of patients in the buprenorphine group compared with 37% in the referral group and 45% in the brief intervention group were engaged in addiction treatment on the 30th day after randomization (P < .001). The buprenorphine group reduced the number of days of illicit opioid use per week from 5.4 days to 0.9 days compared with a reduction from 5.4 days to 2.3 days in the referral group and from 5.6 days to 2.4 days in the brief intervention group (P < .001 for both time and intervention effects; P = .02 for the interaction effect). The rates of urine samples that tested negative for opioids did not differ statistically across groups." (D'Onofrio et al., 2015)

In another paper using the same randomized controlled study with outcomes measured up to 12 months, "A greater number of patients in the buprenorphine group were engaged in addiction treatment at 2 months compared with referral and brief intervention (P < 0.001). The differences were not significant at 6 months (P = 0.37) or 12 months (P = 0.16). At 2 months, the buprenorphine group reported fewer days of illicit opioid use versus referral and brief intervention (P = 0.04). No significant differences in illicit opioid use were observed at 6 or 12 months." (D'Onofrio et al., 2017)

In a cost-effectiveness study of these same three groups, "Considering only health care system costs, cost effectiveness acceptability curves indicate that at all positive willingness-to-pay values, ED-initiated buprenorphine treatment was more cost-effective than brief intervention or referral....emergency department-initiated buprenorphine intervention for patients with opioid dependence provides high value compared with referral to community-based treatment or combined brief intervention and referral." (Busch et al., 2017)