(116) Patient Outcomes After Field-Initiated Buprenorphine With and Without ED Transport

Background & Introduction: The Bupe FIRST program (Buprenorphine Field Initiation of Rescue Treatment) was launched in 2019 by Cooper University Health Care to address a critical gap in post-overdose care for individuals with opioid use disorder (OUD). As the first program in the United States to authorize emergency medical services (EMS) to administer buprenorphine in the field, Bupe FIRST aimed to rapidly relieve opioid withdrawal following naloxone administration and improve linkage to addiction treatment. Buprenorphine administered by trained paramedics reduced withdrawal severity and increased engagement in follow-up care, particularly among patients with frequent overdose-related EMS encounters who are often disconnected from traditional treatment pathways.

This study examines patient outcomes following field-initiated buprenorphine, comparing individuals transported to the emergency department with those who refused transport. Outcomes assessed include engagement in addiction treatment, subsequent EMS utilization, and continuity of care. Findings aim to inform best practices for EMS-based initiation of medication for opioid use disorder and support broader implementation of prehospital buprenorphine across emergency care systems.

Methods: A retrospective chart review was conducted using EMS records and electronic health data to identify individuals who received buprenorphine from EMS providers from 8/1/2020-8/1/2025. Patients were stratified based on ED transport status following buprenorphine administration (transported vs. refused). Extracted variables included demographics, Clinical Opiate Withdrawal Scale (COWS) scores pre- and post-intervention, and follow-up treatment engagement. Participants were excluded if any key variables were missing. Descriptive statistics and bivariate analyses were performed to examine group differences. Multivariable logistic regression was used to evaluate factors independently associated with ED transport refusal.

Results: A total of 261 patients received EMS-initiated buprenorphine during the study period; 169 (64.8%) were transported to the emergency department (ED) and 92 (35.2%) refused transport after receiving buprenorphine. Mean age was 44.5 ± 11.5 years in the transported group and 43.1 ± 12.0 years in the refusal group. Among transported patients, 45.0% were White and 34.9% were Black or African American; among refusal patients, 43.5% were White, 39.1% were Black or African American, and 1.1% was Asian. Most patients were male (69.8% transported vs. 81.5% refused).

Mean pre-treatment Clinical Opiate Withdrawal Scale (COWS) scores were 13.86 in the transported group and 9.54 in the refusal group. Mean post-treatment COWS scores were 5.05 and 2.64, respectively. In bivariable logistic regression, post-treatment COWS score was associated with ED transport status (OR = 1.37, 95% CI 1.20–1.57, p < .001).

Follow-up appointment attendance was 19.5% in the transported group and 20.7% in the refusal group. 30-day treatment engagement distributions were also similar, with 17.2% in the transported group and 21.7% in the refusal group.

Conclusion & Discussion: Post-treatment COWS score was significantly associated with ED transport status, with lower post-treatment scores associated with greater odds of refusing ED transport. This suggests that improvement in withdrawal symptoms following EMS-administered buprenorphine may influence patients’ willingness to accept or decline ED transport. Patients with lower post-treatment withdrawal severity may perceive themselves as sufficiently stabilized to make an informed decision regarding further care.

Despite the expectation that ED transport would serve as a key pathway for linkage to ongoing addiction medicine treatment, follow-up appointment attendance and 30-day treatment engagement were similar between patients who were transported and those who refused. These findings indicate that ED transport may not be the sole determinant of short-term treatment engagement following EMS-initiated buprenorphine.

Taken together, the results highlight the potential importance of prehospital buprenorphine administration as a direct intervention point within the continuum of care. Future work should examine alternative pathways for linkage to care following EMS encounters and identify additional factors that influence patient engagement after field-initiated treatment.

References: 1. Bergstein, R. S., King, K., Melendez-Torres, G. J., et al. (2021). Refusal to accept emergency medical transport following opioid overdose, and conditions that may promote connections to care. International Journal of Drug Policy, 97, 103296.
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3. Carroll, G. G., Wasserman, D. D., Shah, A. A., Salzman, M. S., Baston, K. E., Rohrbach, R. A., ... & Haroz, R. (2021). Buprenorphine field initiation of ReScue treatment by emergency medical services (Bupe FIRST EMS): a case series. Prehospital Emergency Care, 25(2), 289-293.
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