Opioid Use Disorder in the ED: A Case-Based Approach
November 15, 2025 33 minutes read
By Ellen Feldman, MD
Executive Summary
- The emergency department (ED) is a critical touchpoint for identifying, initiating, and linking patients with opioid use disorder (OUD) to ongoing care. The emergency provider should treat OUD as an acute, reversible medical condition.
- Stigma reduction is clinical care. This includes using person-first, nonjudgmental language such as “person with OUD” and “in recovery” to foster trust and improve outcomes.
- The emergency staff can screen for opioid misuse with quick, validated tools such as the National Institute for Drug Abuse single-question screen.
- The Clinical Opioid Withdrawal Scale (COWS) is a validated tool that can be used to quantify the severity of opioid withdrawal by assessing physical and behavioral signs. The COWS score can help guide clinical decisions for initiating or adjusting treatment, monitoring withdrawal progression, and determining appropriate levels of care for patients with OUD.
- ED-initiated buprenorphine with facilitated follow-up improves engagement in treatment and halves the risk of overdose death compared to referral alone. A COWS score ≥ 8-12 is the recommended threshold for buprenorphine initiation.
- Currently, no X-waiver is required for buprenorphine prescribing. Since 2023, any Drug Enforcement Administration-registered provider may prescribe buprenorphine after completing a one-time eight-hour substance use disorder training.
- Methadone may be dispensed in the ED (not prescribed) under the federal 72-hour rule to bridge patients to an opioid treatment program.
- Naloxone saves lives. The emergency provider should consider dispensing two doses (one for the patient and another for a close family member or friend) with education before discharge, regardless of medication for opioid use disorder (MOUD) initiation.
- For acute pain in patients taking buprenorphine, continue the buprenorphine and consider using split dosing for analgesia, along with multimodal therapies and regional anesthesia, and avoid outpatient opioids.
- Limit new opioid prescriptions for acute pain to three days or less and use the lowest effective dose.
- When available, integrate pharmacists and care coordinators into MOUD programs because they can help to streamline access, reduce prescription errors, and enhance follow-up.
- Treat OUD with the same urgency and empathy as any chronic, relapsing disease because one encounter can alter a patient’s trajectory.
Case Presentation
It is 3:00 a.m. Eli, 29-years-old, pale and shaking, leans on the triage counter. “I just can’t stop throwing up.” The patient’s pupils are wide, his skin demonstrates “goose flesh,” and his pulse is 112 bpm with a blood pressure of 152/92 mmHg. He cannot sit still. The nurse asks the routine single question screen: “How many days in the past year have you used any opioid not exactly as prescribed?”
He hesitates. “Honestly … every day for months. Mostly the blue 30s. Last month, fentanyl, whatever I can get. I keep needing more to feel OK.” He looks down at his hands. “I decided this weekend would be it. No more. But I got so sick I couldn’t make it to work. I haven’t slept in two days. I don’t want to use again. I just can’t get through this on my own.”
The nurse marks the screen positive and moves him to a room. Even on a packed night, there is room to treat withdrawal, start medication, and set up follow-up.
Introduction
For many individuals, the emergency department (ED) is the most accessible point of medical contact during the course of their opioid use disorder (OUD). ED clinicians now stand at the crossroads of acute care and chronic disease management, treating overdose, managing withdrawal, and initiating medication for OUD (MOUD). A single encounter, if leveraged effectively, can alter a patient’s trajectory. Studies show that ED-initiated buprenorphine followed by facilitated referral markedly improves engagement in treatment and reduces illicit opioid use and overdose deaths.1-3
During the past two decades, drug-related deaths have surpassed motor vehicle crashes as the leading cause of injury-related mortality in U.S. adults.4 Synthetic opioids, particularly illicit fentanyl analogs, are driving record overdose rates. While ED physicians prescribe only a small fraction of opioids overall, they shoulder a disproportionate share of their consequences, such as overdose reversals, withdrawal, and infections linked to injection use. The ED has evolved from a stabilization-only setting to a frontline treatment site where OUD recognition, withdrawal management, and linkage to ongoing care can occur simultaneously.1-3
Barriers that once constrained ED-based treatment have largely fallen. The elimination of the DATA 2000 “X waiver” and expanded telehealth and follow-up pathways mean that any Drug Enforcement Administration (DEA)-registered provider may now initiate buprenorphine for OUD.5 Clinical guidelines from the American College of Emergency Physicians (ACEP) recommend buprenorphine or methadone as preferred management for opioid withdrawal compared with non-opioid regimens. Evidence supports ED-based immediate medical treatment of opioid withdrawal as both effective and safe when patients exhibit moderate withdrawal.1-3
The ED encounter for a patient enduring opioid withdrawal may be fleeting, but its potential is enormous. For many patients, this is the first time someone offers a medical (not moral) framework for what they are experiencing. A single act, starting medication for withdrawal, providing naloxone, or at the least reframing withdrawal as a treatable medical condition, can begin to dismantle stigma and initiate recovery. Notably, studies have shown that people who start MOUD in the ED have a higher likelihood of continuing in treatment than those who receive only brief counseling. Even more significantly, the risk of death in the days and months following a non-fatal opioid overdose is high; initiating treatment in the ED with medication at the time of the non-fatal overdose cuts this risk by half or greater.1,2,6
Additionally, ED clinicians confront the challenge of distinguishing between therapeutic opioid prescribing and risk amplification. Opioids remain essential for select acute pain conditions, yet overprescribing, especially to opioid-naive patients, has been linked to increased risk of long-term use and misuse. National recommendations endorse the lowest effective dose of a short-acting opioid for no more than three days, coupled with patient education and naloxone co-prescribing when risk factors are present.6,7
The goal of this article is to build confidence in:
- Recognizing OUD rapidly and distinguishing withdrawal, intoxication, and undertreated pain.
- Initiating buprenorphine safely, including for patients exposed to fentanyl and understanding when to consider methadone.
- Treating acute pain with a multimodal plan and when opioids are warranted, prescribing the lowest effective dose for the shortest duration with education and naloxone.
- Using screens and tools without slowing department flow and throughput.
- Linking patients to harm-reduction resources and timely follow-up.
- By the end of this article, ED clinicians will be equipped to turn crisis encounters into opportunities for lasting recovery, one patient, one shift at a time.
Brief Perspective on Substance Use in Medicine
The principles of OUD treatment are embedded in an understanding of addiction medicine and how the medical conceptualization of substance use has evolved over time.
The early history of humanity is sprinkled with references to the use of substances with psychoactive properties. Properties of opium (extracted from the poppy flower) and alcohol (a fermented drink made from honey, rice, or grapes) were known as far back as 10,000 BCE. In ancient Greece, opium and its derivatives were used medicinally and for spiritual purposes, while there is evidence of recreational use of alcohol in the Middle East and China during this time.8,9 Cannabis, originally from Afghanistan, also is deeply rooted in early history. Although practical purposes, such as utility in rope making, fueled its spread through trade, medicinal use followed soon afterward in many areas, including ancient India and China.8,9 These substances spread across the world via trade and cultivation, with written records of specific properties and use in diverse civilizations attesting to a wide range of applications.
The rise of the church after the fall of the Roman Empire seemed to influence significantly beliefs and attitudes toward intoxication, in particular those involving alcohol. In 1647, Agapios, a Greek monk, was the first to document an association between excessive alcohol use and disease. Meanwhile, the “anti-opium” movement began to build, citing medical and moral objections to continued use (and focusing on some of the political implications of ending opium trade).8-10
By the mid-1800s, the addictive potential of opium became known, adding more fuel to the movement to end recreational and medicinal use of this substance. By the early 1900s, the term “addict” became widespread in the United States, and racial stereotypes, especially around cannabis use, emerged. Criminalization of “substances” soared with the passing of the 18th Amendment to the U.S. Constitution, ushering in an era of prohibition.8-10
The repeal of Prohibition in 1933 was followed closely by the establishment of Alcoholics Anonymous in 1935, perhaps a step toward looking at treatment outside of correctional institutions for individuals with disordered substance use.8-10
Yet, with the publication of the first Diagnostic and Statistical Manual of Mental Disorders (DSM) in 1952, through subsequent editions until 1980, substance use was not classified as a standalone disorder but viewed as arising most commonly from a separate disorder of mental health (such as a personality disorder). The third edition of the DSM began slowly to move away from this conceptualization. The 2013 and 2022 editions (DSM-5 and DSM-5 TR) dramatically demonstrated new perspectives on substance use disorder (SUD), basing diagnosis on an understanding of a biopsychosocial model, describing functional impairment and recognizing that SUD presents on a spectrum from mild to severe according to the number of symptoms and degree of impairment.8-11
It is useful to note that societal influences, including political, spiritual, and socioeconomic forces, have contributed to a shifting perception of substance abuse over time, and contributed to our view of SUD and treatment direction today. It is unlikely that the current DSM classification and description of SUD is the final or most definitive word; very well it may be that, as society moves forward, so will our understanding of this disorder, its underpinnings, and its treatment.
For ED clinicians, this evolution matters because it frames what happens in the ED not as an immoral or behavioral crisis, but as an acute episode of a chronic, treatable brain disorder. Understanding this perspective allows ED teams to act decisively and compassionately when a patient presents in withdrawal, overdose, or emotional distress.
Reframing Addiction: Why it Matters in the ED
Addiction is a treatable, chronic medical disease involving disruptions in brain circuits that regulate reward, motivation, and stress response. Genetics (approximately 50% heritability), epigenetics, developmental adversity, mental health comorbidities, and social instability all influence vulnerability. Importantly, the same neurobiological mechanisms that drive compulsive use also make recovery possible: The brain is capable of change.12
Imagine a patient taking an opioid for pain who experiences an immediate rush of relief and well-being. This initial reaction is driven by a rapid flood of dopamine in the brain’s reward pathways paired with potentiated endogenous opioid signaling, forging a powerful link between the drug and pleasure. In time, however, the brain adapts, and baseline dopamine levels fall. Stress mediators (for example, corticotrophin-releasing factor) surge in response to the absence of the drug, and the prefrontal cortex’s ability to regulate impulses weakens, pushing the individual toward more use even when it conflicts with personal values or responsibilities. As tolerance builds, conditioned cues, such as seeing a pill bottle or even the memory of relief, trigger negative reinforcement so that taking the drug becomes more about avoidance of withdrawal symptoms or dysphoria and less about pleasure seeking.13,14
In emergency care, this knowledge helps to explain what clinicians observe at the bedside. When a person in withdrawal reports, “I just need to feel normal,” that experience reflects neuroadaptation. The brain’s reward pathways have recalibrated, making drug use primarily about avoiding distress rather than seeking euphoria. Medications such as buprenorphine stabilize this dysregulated system, reducing craving and restoring control. When provided in the ED, these treatments can begin to reverse a cycle that often has persisted for years. Over weeks to months, patients often reclaim cognitive control and emotional equilibrium, transforming what once felt like an unbreakable cycle into a manageable, chronic condition amenable to long-term recovery.12-14
Viewing addiction through the same lens as other chronic illnesses, such as diabetes or hypertension, supports continuity of care and de-escalates stigma. A brief empathic conversation in the ED that frames OUD as a medical condition, coupled with concrete treatment options, can profoundly shift a patient’s sense of agency and hope.6,15
Why the Focus on OUD Now?
The current opioid epidemic is defined by synthetic opioids, such as illicit fentanyl, which are potent, short-acting, and often combined with stimulants or sedatives. These combinations increase the risk of respiratory arrest and complicate withdrawal. Across the country, EDs are seeing record numbers of opioid-related visits and fatalities. Multiple studies have confirmed that ED access points — medication initiation today, brief risk mitigation — measurably reduce mortality and improve retention compared with referral-only pathways.1-3,6
A Brief Note on Epidemiology and De-Regulation
Although national data indicate a decline in overdose deaths from 2023 to 2024, more than 80,000 Americans still died, more than half from synthetic opioids. Many of these deaths occurred within days or weeks of a prior healthcare encounter.16 Rates of polysubstance involvement, including stimulants and sedative adulterants like xylazine (a veterinary, alpha2 agonist), are rising, further complicating presentations and amplifying overdose risk. These trends make early recognition and initiation of treatment in ED even more central to efforts to curb morbidity and mortality.17
For many patients, the ED is their only access point to medical care, making it a critical setting for initiation of medication for OUD, naloxone distribution, and connection to ongoing treatment.
The Centers for Disease Control and Prevention (CDC) outlines three waves of this epidemic. The initial period began in the late 1990s, shortly after the introduction of oxycodone (approved by the Food and Drug Administration [FDA] in 1995 and the most prescribed pain pill in the United States by 2001); most of the overdose deaths were from prescription opioids marketed initially as “non-addicting.” As the habituating properties of these newer narcotic agents became clear, prescriptions declined, and many patients turned to the street for opioids. The second stage of this epidemic began in 2010 as overdoses with heroin rose. The third wave, beginning in 2013 and continuing to the present day, involves synthetic opioids, especially involving fentanyl (a very potent synthetic opioid marketed as Duragesic or Sublimaze, but also produced illegally).18,19
Recent policy and regulatory shifts have markedly expanded ED clinicians’ ability to deliver OUD treatment. The Mainstreaming Addiction Treatment (MAT) Act in 2023, aimed at expanding access to SUD treatment, eliminated the X-waiver requirement to prescribe buprenorphine and enabled any DEA-registered provider with Schedule III authority to initiate MOUD. A new one-time, eight-hour SUD course to renew or obtain a DEA license now is required as well. However, providers are cautioned to be familiar with state laws regarding MOUD, which may have different requirements.5
Federal telehealth flexibilities, extended through at least Dec. 31, 2025, permit both initiation and continuation of buprenorphine via virtual encounters without a prior in-person examination. Concurrently, naloxone’s transition to over-the-counter status and state-level standing orders have helped in equalizing overdose reversal access and streamlined co-prescribing. Together with streamlined training requirements (the one time, eight-hour SUD continuing medical education course to renew a DEA license) and evolving reimbursement codes, these regulatory changes position the ED in the center of the frontline for initiation of evidence-based OUD treatment and harm-reduction measures, such as naloxone prescribing and linking patients to follow-up care.3,5
Yet, the uptake of ED MOUD remains hindered by lingering knowledge gaps, concerns about availability of follow-up, workflow/time constraints, and basic access issues. Recognizing the need for clear guidelines for treatment, the American College of Emergency Physicians (ACEP), drawing from extensive literature review and clinical expertise, published a consensus paper in 2021 outlining the evidence-based recommendations for treatment of OUD in the ED. These include identification of patients with OUD, suicide screening, initiation of appropriate pharmacotherapy, and direct linkage to follow-up care.2
Stigma: A Persistent Barrier in Acute Care
Stigma is a powerful social mechanism shaped by attitudes and/or behaviors, including labeling, stereotyping, and separating, which contribute to loss of status and discrimination. Stigma in healthcare and in health facilities can be especially damaging, leading to poor outcomes for vulnerable individuals and affecting the healthcare workforce as well. Increasingly, it is becoming clear that recognition and correction of stigmatizing attitudes and behavior is essential to delivering quality healthcare.17,18
Individuals with mental illness, and particularly those with SUD, report that both overt stigma and perceived stigma are barriers to seeking treatment. In recognition of this and as one of several concrete steps to encourage clinicians to recognize and correct stigmatizing behaviors, several prominent medical societies (including the American Medical Association and ACEP) actively promote the use of accurate scientific terminology when discussing substance use and SUD.20
“Words matter,” noted Botticelli and Koh in the Journal of the American Medical Association (JAMA) in 2016, Slomski in JAMA in 2021, and Judd H et al in 2023.21-23 All of these articles advocated for removing stigmatizing language from the everyday vocabulary of medical professionals, noting this can be an effective first step toward starting to change bias and perceptions of other healthcare workers, patients, and the general public. For example, describing the patient as “a person with SUD” rather than labeling the individual a “drug abuser” or “addict” reinforces the concept that SUD is a treatable medical condition rather than a personal characteristic or failing. Other recommendations include avoiding the term “drug habit,” which may convey a sense of choosing to use (rather than using because of chronic brain disease) and to discuss individuals being “in recovery or relapse” rather than “clean or dirty.”21-23
Certainly, vocabulary changes alone must be matched with education and policy changes on many levels to defeat the stigma associated with SUD. Notably, in the ED, the effect of stigma is magnified because encounters are brief and emotionally charged. All members of the ED team can begin the process of defeating stigma and pull down some of the barriers surrounding access to treatment for patients with SUD by careful choice of medically accurate neutral terms that portray SUD as a treatable, chronic medical condition.
Diagnostic Principles in the ED
Diagnosis of OUD in the emergency setting can be rapid and pragmatic. The DSM-5-TR gives concrete guidelines for the diagnosis of “substance-related and addictive disorders.” Note that none of these disorders are referred to as “addictions” but are classified as SUD. Substances specified in DSM-5-TR include alcohol, caffeine, cannabis, hallucinogens, inhalants, opioids, sedative/hypnotics, stimulants, and tobacco.11 For most of these categories (apart from caffeine), the diagnostic criteria are as follows:
A problematic pattern of use leading to clinically significant impairment or distress, as manifested by at least two of the following over a 12-month period:11
- taking more than intended;
- inability to reduce or control use;
- spending a lot of time obtaining, using, or recovering from use;
- experiencing cravings;
- continued use despite failure to fulfill major obligations;
- continued use despite deterioration in interpersonal or social relations caused by use;
- giving up important social, occupational, or recreational activities because of use;
- recurrent use in a hazardous situation;
- continued use despite knowing use will worsen physical or psychological problems;
- tolerance to the effects of the substance; or
- withdrawal when reducing or stopping use.
Severity is determined by the number of criteria met. Two to three criteria indicate a mild disorder, four to five criteria indicate a moderate disorder, and six or more criteria indicate a severe disorder. Early or sustained remission also may be documented. Note that there is no distinction made between “abuse” and “dependence.”11
ED clinicians often rely on focused history, observation, and collateral information to identify OUD. Timely intervention is the key. Confirming that the patient meets clinical criteria for OUD and is medically stable allows for immediate action, such as initiating buprenorphine, managing withdrawal symptoms, and/or coordinating follow-up with community or inpatient services.
Treatment
Treatment of SUD can fall into two general categories: pharmacologic and non-pharmacologic. In the best of worlds, these two modalities are intertwined into an individualized treatment program. However, many patients receive neither of these interventions.
Before initiating treatment, it is useful for the ED clinician to develop a working understanding of the American Society of Addiction Medicine (ASAM) “dimensions,” which lend a structured approach to determining the level of care for an individual patient. These dimensions consider the complex, multifactorial nature of substance abuse. Dimensions 1-5 can be used to consider the level of care needed medically, while dimension 6 involves joint decision-making.24,25
Dimension 1: Consider the state of intoxication, withdrawal stage, and addiction medications. A careful history can help determine if this patient can be treated safely in the ED.
Dimension 2: Biomedical Condition. Consider unstable comorbidities that may require inpatient services, such as chronic liver disease, any pregnancy-related concerns, or sleep issues.
Dimension 3: Psychiatric, cognitive, and behavioral comorbidities, such as mood disorder, psychosis, and/or suicidal threats that require psychiatric care.
Dimension 4: Substance use-related risks, including the likelihood of risky behavior.
Dimension 5: Recovery environment interactions, including safety and support in the current environment.
Dimension 6: Person-centered considerations, including motivation, patient preferences, and barriers to care.
Considering each factor can help the ED provider make a focused, medical decision regarding whether initiation of pharmacotherapy can begin safely in an ED setting. Other options for more intensive care include a rehabilitation center, a psychiatric inpatient facility, or a medical center.4,23
It is essential for the ED team to have a working knowledge of resources in the community and/or online offerings to provide the patient to refer for follow-up, since the ED can offer only initiation of treatment. (See Table 1.)
Table 1. Key Points for Emergency Department Clinicians | |
Focus Area | Key Actions/Takeaways |
Prescribing Authority |
|
Diagnosis & Treatment Framework |
|
Language & Stigma Reduction |
|
Continuity of Care |
|
DEA: Drug Enforcement Administration; MOUD: medication for opioid use disorder; SUD: substance use disorder; ASAM: American Society of Addiction Medicine; DSM-5-TR: Diagnostic and Statistical Manual of Mental Disorders, 5th edition, text revision; ED: emergency department; OUD: opioid use disorder | |
Back to the Case of Eli
Clinician: “I just spoke with the nurse you met at triage. We appreciate your honesty today. That could not have been easy to share.”
Eli (eyes downcast): “I feel very ashamed. I have a good job, and a family. But I feel like I am becoming an addict.”
Clinician (nodding in understanding): “The symptoms you describe — including ‘chasing the pills’ — indicate you have a moderate opioid use disorder. This means your brain chemistry adapted to the opioids. The good news is that this is a chronic but treatable medical condition, and we may be able to start treatment today, to stabilize you and reduce cravings, if you are ready.”
Eli (looking up): “Today? Really? I thought you would maybe refer me somewhere.”
Clinician: “Yes. There is an option for referral to a specialty clinic, if you prefer that route. Right now, the wait is at least two to three months, but the clinic has addiction specialists on-site. Most patients prefer to start here in the ED and use the support services from their primary care provider and eventually the specialty clinic once they are available.
“But, regardless, the first step is to see where you are in terms of withdrawal. I use a tool called the Clinical Opiate Withdrawal Scale (COWS), which measures signs and symptoms of withdrawal. By my calculations, you score in the mild to moderate range, which indicates your body now depends on opiates to function.”
Eli (looking alarmed): “Yes, I know I am in withdrawal — with or without the scale! Do I just have to get through it? I don’t think I should wait a month or more. I would probably use again.”
Clinician: “I think we can help you out. Let me gather a little more history, check you out physically, and then we will go over some options. You will need some labs, but let’s take this step by step.”
After confirming that Eli has no unstable comorbidities, has no new prescriptions on the state database (Prescription Drug Monitoring Program [PDMP]), and is in a stable home environment, the clinician feels ready to offer treatment options.
Some ED tools for MOUD include the following:
Screens for OUD
The National Institute for Drug Abuse (NIDA) provides a quick screen for substance misuse, accompanied with reassurance that the information will be used for diagnostic and treatment purposes. The basic question: “In the past year, how often have you used the following substance?” can be modified for clinical purposes, as seen in the initial encounter with Eli.26
Clinical Opiate Withdrawal Scale (COWS)
This 11-item scale rates clinical signs and symptoms of opiate withdrawal, such as pulse rate, nausea/vomiting, yawning, agitation, and tremor, and allows monitoring over time.27 Scores range from 0-47: 0-4 indicates no active withdrawal, 5-12 indicates mild withdrawal, 13-24 indicates moderate withdrawal, 25-36 indicates moderately severe withdrawal, and > 36 indicates severe withdrawal. These scores often are used to guide when to initiate buprenorphine and subsequent dosing, along with clinical observation and patient experience. Waiting to initiate MOUD until a patient is in at least moderate withdrawal (COWS score ≥ 12) generally is recommended to avoid precipitated withdrawal, although some protocols consider induction at a score ≥ 8.1,2,25,27
Prescription Drug Monitoring Program (PDMP)
These are state-run electronic databases that collect information on all dispensed controlled medications to an individual.28 Accessing the PDMP allows clinicians to see dispensing history. This information is best used to provide safe treatment and not to judge a patient or refuse care. Sharing PDMP findings transparently can open a dialogue that builds trust. For example, “I see here you have recently filled scripts from two providers. Let’s talk through what is happening so we can safely manage your treatment.”
Although concurrent use of buprenorphine and sedatives heightens the risk of negative outcomes (including overdose and respiratory depression), this is not a reason to refrain from initiating buprenorphine in the ED since the potential harm of untreated OUD is far greater.1,2,25,29
Depression and Suicide Screens: Patient Health Questionaire-2 (PHQ2) and Columbia Suicide Severity Rating Scale (C-SSRS)
Patients presenting to the ED with opioid withdrawal frequently have co-occurring depression and are at an elevated risk for suicidal ideation or behavior. The acute dysphoria, hopelessness, and anxiety that accompany withdrawal can transiently intensify underlying mood symptoms. Screens such as the PHQ2 and/or the C-SSRS have a place in the initial evaluation.30,31 Identifying mood symptoms early allows for appropriate crisis intervention, safety planning, and linkage to follow-up care. Even when withdrawal is the presenting complaint, asking directly about suicidal thought signals compassion and can reveal treatable psychiatric illness that might otherwise go unrecognized.1,2,25,29
Shared Decision-Making
The clinician explains options for treatment.
Standard induction: “We can start buprenorphine now when your withdrawal is moderate. This would be a sublingual dose — under your tongue — and you would need to stay for monitoring. We will check in with you every hour or so. Depending on your withdrawal stage, we will give you more in titrating doses. This should help you feel better quickly, but I want you to know there is a risk of feeling worse if our timing is off and you still have opioids on board.”
Micro-induction: “This second option is still considered off-label. This method uses very low doses of buprenorphine over several days while you taper your current opioids. This makes sense if you still have opioids in your system now and will help avoid significant withdrawal, but you need to check in daily here or with your primary care provider for several days to weeks.”
Note: Buprenorphine’s high affinity for mu-opioid receptors means it can displace full agonists (like fentanyl) and trigger sudden, intense withdrawal if these agonists still are present. As noted, to minimize this risk, patients should be in at least moderate withdrawal (COWS score of 12 or greater but less than 20) before standard induction. The presence of fentanyl can heighten this risk because this substance is highly lipophilic, often leading to prolonged receptor occupancy and consequently heightening susceptibility to precipitated withdrawal.1,29,32
Eli (looking away): “I want to feel better as quickly as possible, and I am committed not to use again. I promised my wife after she found my pills last week.” Taking a deep breath, he turns to face the clinician. “I think her disappointment was worse than any withdrawal. I used fentanyl but not for weeks — it scares me. Let’s do the first option.”
Pharmacotherapy for Opioid Use Disorder
Buprenorphine (partial μ-agonist and κ-antagonist)
This agent lightly activates the same opioid receptors that full opioids (like fentanyl or morphine) stimulate, reducing cravings and withdrawal without producing the same high. At the same time, it blocks other opioid effects (κ-antagonism), which can help decrease dysphoria and lower the risk of misuse.1,2,25,29,32
Formulations: Sublingual (SL) films/tablets (with or without naloxone), monthly depot injection, six-month implant for select stable patients. Patients should be instructed to keep the tablet or film under their tongue for at least 15 minutes until fully dissolved, without eating, drinking, or smoking during this time.1,2,29
Initiation: Induction in the ED (doses typically are higher than induction in an outpatient setting because of time factors and severity):1,2,25,29,32
1. 4 mg to 8 mg SL at COWS score ≥ 8-12, recheck in 40 minutes.
2. Titrate in 4-mg to 8-mg increments to 16 mg to 24 mg based on relief of withdrawal symptoms.
3. Prescription: Begin with the total dose from ED (may be split if patient prefers) with instructions to taper to 24 mg as clinically indicated.
4. If the patient remains in withdrawal after 24 mg, return to the ED for further dosing under observation.
Note: Typical daily dose is 16 mg to 24 mg, with evidence that < 16 mg daily is less effective than higher doses at suppressing opioid misuse. There is emerging evidence that doses up to 32 mg may be necessary to successfully retain individuals in treatment, especially those exposed to fentanyl previously. (See Tables 2 and 3.)
Table 2. Buprenorphine Pharmacotherapy | ||
Step | Action | Details/Notes |
Initial Dose | Administer 4 mg to 8 mg sublingual (SL) when COWS score ≥ 8-12 | Reassess withdrawal symptoms after 40 minutes |
Titration | Give additional 4 mg to 8 mg SL increments as needed | Titrate based on relief of withdrawal symptoms; typical total dose is 16 mg to 24 mg |
Prescription on Discharge | Prescribe total ED dose (may be split if patient prefers) | Instruct patient to taper to 24 mg daily as clinically indicated |
Persistent Withdrawal | If symptoms persist after 24 mg, patient should return to ED for further observed dosing | Continue monitoring for safety and response |
Clinical Notes: Typical effective daily dose: 16 mg to 24 mg. Doses < 16 mg often are less effective at suppressing opioid misuse. Higher doses (up to 32 mg) may be needed for patients previously exposed to fentanyl to achieve retention in treatment. COWS: Clinical Opiate Withdrawal Scale; ED: emergency department | ||
Table 3. Medications Commonly Used in the Emergency Department for Opioid Use Disorder |
Buprenorphine (with or without naloxone)
|
Methadone
|
COWS: clinical opiate withdrawal scale ; ECG: electrocardiogram; ED: emergency department |
Management of Precipitated Withdrawal
Precipitated withdrawal looks like opiate withdrawal but comes on abruptly (compared to the gradual onset of withdrawal symptoms) and typically occurs within an hour of buprenorphine administration. Some patients who have experienced precipitated withdrawal may want to avoid buprenorphine; it is useful to ask a patient about previous experiences with this agent prior to starting induction and use shared decision-making and patient education to decide on the best treatment course.
Medical management of precipitated withdrawal generally involves higher doses of buprenorphine — up to 64 mg to saturate receptors and adjunctive medications to treat symptoms. These often include antiemetics for nausea and vomiting, alpha-adrenergic agonist for autonomic hyperactivity, and antipsychotics for agitation.1,2,29,32
Micro-induction (gradual low-dose schedule over five to seven days for fentanyl-exposed patients). Note: micro-induction protocols remain off-label, since these have not received formal FDA approval but are supported by emerging clinical evidence and expert consensus to mitigate precipitated withdrawal risk.1,2
Side effects: Usually less intense than full agonists, but may include sweating, tongue pain, vomiting, and agitation.1,2,25,29
Maintenance dosing: The goal is once-daily dosing up to 16 mg to 24 mg daily with no withdrawal between doses; higher doses may be needed to suppress fentanyl-driven cravings.1,2,25,29
Laboratory monitoring: Order baseline laboratory tests immediately; the results will inform follow-up care, but do not delay treatment or the first dose to wait for results. Recommendations include urine drug screen, liver enzymes, serum bilirubin, pregnancy test, and tests for hepatitis B and C and human immunodeficiency virus (HIV); complete blood count (CBC) and urine creatinine if clinically indicated.1,2,25,29
Safety monitoring “ceiling effect”: Increasing dose does not increase side effects (including respiratory depression or euphoria) but reduces overdose risk. It is important to monitor for sedation after induction and taper benzodiazepines if these are being concurrently used, since this combination may lead to significant respiratory depression.1,2,25,29
Combination with naloxone: Co-formulating buprenorphine with naloxone (e.g., Suboxone) is designed to deter misuse by injection. If taken as prescribed sublingually, naloxone has minimal systematic effect; however, if dissolved and injected, naloxone precipitates acute withdrawal, reducing the incentive for intravenous diversion. Despite this safeguard, diversion still occurs. Clinicians should counsel patients on secure medication storage, safe handling, and the legal implications of sharing or selling their prescription.33
Management of ancillary symptoms during induction and stabilization: Non-opioid medications, including clonidine for autonomic symptoms, hydroxyzine for anxiety, ondansetron for nausea, loperamide for diarrhea, nonsteroidal anti-inflammatory drugs (NSAIDs) and acetaminophen for pain, and trazodone for sleep, can enhance comfort during this stage.1,2,25,29
Methadone
Formulation: Multiple forms are available, most commonly oral (tablets or liquid) but available for injectable or subcutaneous administration.34,35
Initiation: This opioid agonist is highly effective for the treatment of OUD. In the United States, methadone maintenance is permitted to be prescribed only within an opioid treatment program (such as a methadone clinic). However, initiation of methadone or continuation of methadone may be performed in the ED under the 72-hour rule, which allows dispensing (not prescribing) of methadone from the ED for up to three consecutive days to relieve symptoms of withdrawal while the patient is referred to or awaiting treatment at a registered program. EDs that can take advantage of this policy must be affiliated with an organization (typically a hospital) with protocols and processes for dispensing of methadone and a linkage to a licensed methadone clinic.34,35
Is there any advantage over buprenorphine?
- There is no risk of precipitated withdrawal — consider for patients using fentanyl;
- Patients who have had a negative experience with buprenorphine;
- Patients who have had positive responses to methadone.34,35
Caveats: If a patient on methadone maintenance arrives in the ED, be mindful of drug interactions and the risk of overdose and methadone toxicity, especially if methadone is combined with sedative-hypnotics. Providers should be cognizant that methadone can cause QT interval prolongation, increasing the risk of torsades de pointes, and should assess for baseline electrocardiogram (ECG) abnormalities and be cautious with the use or administration of concurrent QT-prolonging medications. There also are medical risks if a patient involved in a methadone program combines this substance with illicit drugs. For example, use of cocaine combined with methadone may lead to clinically significant prolongation of the QT interval.34,35
A word about naloxone alone: This opioid antagonist rapidly reverses an opioid overdose. This does not treat OUD but can be lifesaving should an overdose occur. Prescriptions for this agent include a “naloxone kit,” and formulations include injectable, intranasal, and auto-injector. Prescribe two: one for the patient to keep with them and one to give to a trusted friend.1,2,36,37
In 2023, the FDA approved the first nasal spray naloxone available over the counter. Although this has improved access to this potentially life-saving medication, stigma and cost continue to be barriers.36,37
Back to Eli
Clinician: “We will start with a 4-mg sublingual dose. In about 40 minutes, the nurse will recheck your pulse and blood pressure, and I will take a look to see how you are doing.”
Eli: “So I just sit here?”
Clinician: “Actually, you will be busy. The lab will come in to draw some blood, and I have some information for you to read and a short video about harm reduction, support groups, and therapy options. Our OUD health coach should arrive soon and will be checking in with you to explain the program and help arrange a follow-up schedule that works for you. Then it will be time to meet Dr. L, our OUD pharmacist, who will explain the naloxone kit. I prescribed two of these for you. One to keep with you and one to give to someone you trust.”
About 45 minutes later, Eli’s COWS reassessment has dropped to 10. The laboratory tests have been completed, and results are starting to post. Over the next two hours, he gets an additional 12 mg of SL buprenorphine, remains stable, and is discharged with a COWS score of 5. He leaves with a three-day prescription of the agent (16 mg daily based on his initial needs), timely follow-up with a local clinic that accepts his insurance (three days later), two naloxone kits, and hand-outs.
Some take-home points to consider are:
- COWS provides a standardized way to time induction; aim for ≥ 8-12 but < 20 for standard protocol. In addition to COWS, use clinical observation, patient history, and patient experience to determine timing and dosage.
- Initiate buprenorphine without waiting for laboratory test results or counseling enrollment.
- Dispense naloxone kits (two: one for home and one for a friend) with brief training before discharge.
- Provide a clear handout and education regarding harm reduction and direct referral — with appointment if able — for ongoing care.
- Order baseline laboratory tests immediately: CBC, pregnancy test (if applicable), liver enzymes, serum creatinine, and screening tests for hepatitis B, hepatitis C, and HIV. Draw blood during observation period so results inform follow-up care, but do not delay the first dose of buprenorphine.
Team-Based Care: Pharmacist Integration in MOUD
Integrating pharmacists into MOUD delivery has been associated with improved retention, fewer medication errors, and increased clinician capacity for patient-facing care. Models range from co-located pharmacists to telepharmacy support.38 In such settings, roles of the pharmacist typically include:
- Dispensing and medication management: verifying prescriptions and dispensing formulations;
- Patient counseling and education: providing in-depth medication counseling on induction expectations, proper administration techniques, safe storage and diversion prevention; offering brief proactive follow-up contacts to assess adherence and side effects;
- Clinical monitoring and coordination: monitoring for drug-drug interactions, reviewing laboratory data, and flagging abnormal results for provider review;
- Workflow: managing prior authorizations, insurance navigation, and setting up refill alerts and naloxone co-prescribing prompts;
- Quality improvement: track metrics such as adherence rates, naloxone distribution, 30-day retention, etc.38
Eli: Two Years Later
Eli walks slowly into the ED, holding gauze to his upper lip. Dried blood traces a line from his nose to his chin. He looks alert but in pain.
“Triage first,” the nurse says, guiding him to a chair. “Name and pain level?”
“Eli. It’s an 8. I crashed my bike. I must tell you; I’m on buprenorphine every morning.”
“When was your last dose?”
“7 a.m.”
She nods, collects more demographic information, places a wristband, and moves him to his room.
The ED doctor enters, introduces herself, and examines Eli’s face. “Hmm. Looks like a nasal fracture and a lip laceration. Pupils are normal. No neck tenderness. Any other injuries?”
“Just the face. Luckily, I had a good helmet. But my face hurts. I’m worried how to treat the pain because I’ve been on buprenorphine for two years and I don’t want to lose ground. It took a while to get stable.”
“OK. We’ll control your pain and repair the lip. We’ll keep your buprenorphine on board and probably will split your usual dose across the day. We’ll start with acetaminophen and ibuprofen, and I can numb the area for repair. If you still hurt, we can add a small ketamine dose. If pain breaks through after that, we can treat it with a small dose of a full opioid here under monitoring. No mixed products, meaning no meds that combine an opioid with acetaminophen, for instance. That way we can adjust each dose independently.”
Eli nods. “I want the pain down, but I don’t want to lose the progress I’ve made.”
“Understood.” Says the clinician. “I’ll also check the PDMP. It is a state database — just to make sure there’s no other agents to consider and call your clinic before you leave.”
After imaging confirms a broken nose without other injuries, the ED physician returns.
“Your nose looks broken but does not need urgent surgery. The lip needs stiches. We can do an infraorbital nerve block to take the edge off.”
“I’m in,” says Eli.
“You’ll feel a sting near your upper gum, then it should go numb.”
Eli winces, then exhales. “That helps already.”
As the block sets in, the conversation continues. “You’ll continue your buprenorphine. For the next day or two, split your daily dose morning and evening to help with pain control. Take the scheduled acetaminophen and ibuprofen unless you have a reason not to. Ice and keep your head up. If your pain is still severe here, we can give a small dose of hydromorphone before you leave. We won’t send an outpatient opioid, but we will give you a clear plan and fast follow-up.”
“That sounds reasonable,” says Eli. “And I appreciate that you recognize that I want to avoid outpatient opioids.”
The wound is irrigated and sutures replaced. “How’s the pain?” inquires the ED doctor.
“Manageable,” says Eli. “Especially with the numbness.”
The nurse hands over written instructions. “These are your dosing times, wound care steps, and return precautions. Your naloxone is listed here, too.”
The physician calls Eli’s MOUD clinic on speaker. “Hello, this is Dr. F in the ED. Your patient Eli is here after a bike crash. We repaired a lip laceration. His nasal fracture is stable. I’m recommending for him to continue the buprenorphine, split dosing for analgesia. No outpatient opioids. Can you see him this week?” The clinic confirms a next-day slot.
Back with Eli, the physician summarizes. “You are set for clinic tomorrow. Continue buprenorphine as we discussed. Use acetaminophen and ibuprofen on schedule. Ice today and tomorrow. If bleeding restarts and will not stop, or if swelling closes an eye, return immediately.”
Eli sits up, now steady. “Thank you for treating the pain and keeping me on track.”
“That is the goal,” says the attending. “Safe pain control and no lost ground.”
Summary Take-Home Points
It is crucial that when diagnosing and initiating treatment for OUD, clinicians should apply a chronic disease framework and use non-stigmatizing language. Efficient universal or targeted screening for unhealthy substance use should be implemented, distinguishing risky use from SUD according to DSM-5-TR criteria. When evaluating a patient using substances, an OUD severity score should be assessed, and the appropriate level of care should be determined using practical adaptations of ASAM dimensions. Outpatient opioid prescriptions should be limited for all patients, providing no more than three days at the lowest effective dose. Moreover, while not delaying life-saving medications and interventions, the emergency provider also should employ harm-reduction strategies in the care of individuals with SUD. Importantly, if they are available, psychosocial and wrap-around supports should be coordinated.
Ellen Feldman, MD, is with the Department of Behavioral Health, Altru Health System, Grand Forks, ND.
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The emergency department (ED) is a critical touchpoint for identifying, initiating, and linking patients with opioid use disorder (OUD) to ongoing care.
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