Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health

Introduction: Initiation of buprenorphine reduces mortality in people with opioid use disorder. However, patients who decline hospital transport after overdose may not be connected to treatment. To augment treatment engagement, prehospital buprenorphine pilot programs began in 2019. To date, few studies have looked at these programs nationally. Our objective was to evaluate national prehospital buprenorphine usage.

Methods: We conducted a cross-sectional evaluation of emergency medical service (EMS) encounters involving prehospital buprenorphine administration using the 2020-2023 National EMS Information System Public Release Research datasets. Our primary outcome was trends in prehospital buprenorphine usage. Quarterly rates of prehospital buprenorphine were evaluated using joinpoint regression to identify inflection points. The secondary outcome was patient demographics and encounter characteristics, which were analyzed using descriptive statistics.

Results: Of all EMS encounters with patient contact in the dataset (N = 167,221,959), there were 2,180 encounters where buprenorphine was administered (62% male [n = 1,349], mean age 37 years, standard deviation [SD] 10), with a significant increase per year (2020: n = 33; 2023: n = 1,574). Approximately half (52%; n = 1,125) of prehospital buprenorphine administrations occurred during 9-1-1 responses. Most encounters occurred in the South Atlantic region (4 administrations/100,000 encounters) and urban areas (72%; n = 1,572). Nearly all EMS crews were advanced life support (ALS) level of care (paramedic: 53% [n = 1,155]; ALS-community paramedic: 46% [n = 1,008]). Initial dosages of administered buprenorphine were 8 milligrams (mg) (45%; n = 973), 16 mg (36%; n = 786), or 24 mg (7%; n = 160). Most patients (80%; n = 1,746) had documented improvement with only four (0.2%) worse after administration. Few 9-1-1 encounters (16%; n = 180) resulted in hospital transport by EMS. Only 7% (n = 82) of 9-1-1 prehospital buprenorphine encounters had documented naloxone administration prior to buprenorphine dosing. There was a significant increase in number of buprenorphine administrations in quarter 2 of 2022 (slope increase of 54 administrations [95% CI, 20-89] per quarter versus 1 administration [95% CI, –1 to +3] per quarter from 2020-2022 quarter 1).

Conclusion: Rates of prehospital buprenorphine have increased significantly between 2020 and 2023. Buprenorphine administration largely resulted in documentation of improvement in patient condition. With continued high rates of opioid-related deaths, prehospital buprenorphine may be considered by EMS agencies to prevent deaths from subsequent opioid use and connect patients to treatment.