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Reaching people where they are–using EMS to start buprenorphine

January 10, 2023

Emergency medical services (EMS) are a critical first-response system in the opioid overdose crisis; EMS patient encounters involving an opioid overdose have risen in recent years. People may be particularly receptive to starting treatment after an overdose. This may be done, for example, in an emergency department if someone is taken there after his or her overdose.

However, many survivors of non-fatal opioid overdose refuse EMS transport or leave the hospital prior to being engaged in treatment. (1–3) This means that there are missed opportunities to start patients on methadone and buprenorphine, the two medications with the strongest evidence supporting their use in treating people with an opioid use disorder in the emergency department.

To increase treatment engagement among survivors of non-fatal opioid overdose, clinicians at Cooper University Health Care in Camden, New Jersey, initiated a novel protocol: Buprenorphine Field Initiation of Rescue Treatment by EMS (Bupe FIRST). (4) Through the Bupe FIRST intervention, some survivors of non-fatal opioid overdose received:

  • Buprenorphine on location by the EMS personnel;
  • Addiction resources; and
  • A clinic appointment for the same or the next business day to continue their treatment.

While buprenorphine has been proven to save lives as part of outpatient treatment, (5) the approach of using it in the pre-hospital setting directly after overdose had not been tried before. Through a temporary executive directive, the state allowed buprenorphine administration by paramedics with strict physician oversight as part of the Bupe FIRST intervention. Researchers from Johns Hopkins Bloomberg School of Public Health, in collaboration with clinicians and researchers at Cooper University Health Care, examined the Bupe FIRST intervention to explore this question. (6)

The study found that delivering buprenorphine in this way was associated with a nearly six-fold increase in the odds of engagement with substance use disorder treatment (i.e., visiting a substance use disorder clinic) within 30 days of an overdose-related EMS encounter. This represents a dramatic success in getting patients connected to follow-up care. However, the project did not find that starting people on buprenorphine in a pre-hospital setting reduced the chance of a repeat overdose in the immediate 24 hours or seven days compared to people who did not get started on the medication. (Though it is worth noting that patients who were not started on the medication in the field could also get buprenorphine in the hospital, which could reduce their overdose risk).

As states determine how to invest their opioid litigation funds, they should consider the role of pre-hospital buprenorphine programs. These programs do require some upfront investment in training and staffing, but can provide a critical new access point to starting patients on life-saving medication treatment. Overall, pre-hospital buprenorphine provides another chance to expand the reach of treatment to patients wherever they are and to give them a new onramp to treatment.


  1. Rhee TG, D’Onofrio G, Fiellin DA. Trends in the Use of Buprenorphine in US Emergency Departments, 2002-2017. JAMA Netw Open. 2020;3(10):e2021209. doi:10.1001/jamanetworkopen.2020.21209
  2. Glenn MJ, Rice AD, Primeau K, et al. Refusals After Prehospital Administration of Naloxone during the COVID-19 Pandemic. Prehosp Emerg Care. 2021;25(1):46-54. doi:10.1080/10903127.2020.1834656
  3. Rock P, Singleton M. EMS Heroin Overdoses with Refusal to Transport & Impacts on ED Overdose Surveillance. Online J Public Health Inform. 2019;11(1):e430. doi:10.5210/ojphi.v11i1.9917
  4. Carroll GG, Wasserman DD, Shah AA, et al. Buprenorphine Field Initiation of ReScue Treatment by Emergency Medical Services (Bupe FIRST EMS): A Case Series. Prehosp Emerg Care. 2021;25(2):289-293. doi:10.1080/10903127.2020.1747579
  5. D’Onofrio G, O’Connor PG, Pantalon MV, et al. Emergency Department–Initiated Buprenorphine/Naloxone Treatment for Opioid Dependence: A Randomized Clinical Trial. JAMA. 2015;313(16):1636-1644. doi:10.1001/jama.2015.3474
  6. Carroll G, Solomon KT, Heil J, et al. Impact of Administering Buprenorphine to Overdose Survivors Using Emergency Medical Services. Ann Emerg Med. Published online October 1, 2022. doi:10.1016/j.annemergmed.2022.07.006

Keisha Solomon, Ph.D., the contributing author of this post, is an applied microeconomist and research scientist at Howard University. Her primary research interests lie at the intersection of health and public economics, policy analysis, applied microeconometrics, and studies of poverty and inequality. Keisha previously worked as a postdoctoral fellow at Johns Hopkins Bloomberg School of Public Health (BSPH) with an interdisciplinary research team on the evaluation of state policy efforts related to opioids for a project funded by Bloomberg Philanthropies. During her postdoctoral training, her research team at BSPH conducted a collaborative study, which this post summarizes, with clinicians and researchers at Cooper University Health Care.