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A team of emergency physicians urged colleagues to cast off their hesitation and start initiating treatment with the opioid withdrawal drug buprenorphine in the emergency department.

"We're usually the first to charge into a room, yet this has been an area where we have really been slow and reluctant. But this is actually a fantastic tool that can make a difference in a patient's life," said Portland, Oregon, emergency physician Arian Nachat, MD, in a presentation at the .

Buprenorphine, an opioid partial agonist, is used to treat opioid withdrawal. It may be combined with naloxone (as Suboxone) to prevent abuse.

A found that only 44% of 93 emergency physicians surveyed said they'd feel comfortable discussing buprenorphine as an addiction therapy with a patient who's experiencing withdrawal and wants treatment. The percentage was low even though 80% of those surveyed said they think buprenorphine should be prescribed in the emergency department.

Nachat, who highlighted the study findings, has a theory about the hesitancy of emergency physicians to prescribe the drug: "We have struggled so much with patients with chemical dependency that there's this sense of impotence that we may not be able to help this patient, and they're just going to come right back in."

In fact, she said, "we may not be able to get all of these patients across the finish line, but at least we start them on the right path."

Contrary to popular belief, ED physicians can prescribe buprenorphine in certain cases without needing an from the Drug Enforcement Agency, said Kurt Kleinschmidt, MD, an emergency physician at UT Southwestern Medical Center in Dallas, who also spoke during the ACEP presentation. "This often gets confused. You can administer it in the ED to get somebody out of withdrawal. If you've had your X-waiver, you can also give them a prescription to initiate [maintenance] treatment for long-term addiction care."

X-waivers are available to licensed physicians after 8 hours of training, Kleinschmidt said, and are available for free. "The good news is your DEA license number really has not changed. You just get an X that's added to the beginning. So it's not like you have to go back and memorize a whole new DEA number as you move forward."

Speakers at the presentation suggested that emergency physicians keep certain points in mind.

Make sure the patient is actually experiencing withdrawal symptoms, Kleinschmidt said. "If the person has physical dependence to opioids, they're not in withdrawal. If you give them buprenorphine, you can induce withdrawal."

Also, if patients initially appear reluctant due to previous experiences, it may be because they had taken it before withdrawal actually set in, said emergency physician Alexis M. LaPietra, DO, of St. Joseph's Health in New Jersey.

Adjust the dose based on the level of withdrawal by using the , LaPietra said. Give 8 mg sublingual if the score reaches 8 or above, she said, adding that patients must understand they can't chew or swallow it or else it won't work.

Another dose upon re-evaluation can be appropriate, she said. "There's no adverse event to going higher, no apnea." But if patients don't improve, consider that they may need other interventions because they're taking other drugs, she said.

LaPietra also recommended use of buprenorphine in the ED even if it's not clear if the patient will seek addiction treatment once they leave. Consider addiction to be a chronic medical disease, she said, "and mobilize your team to have a good transition of care if possible" to outside addiction therapy.

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