Andrew A. Herring

Objectives: Addiction consult services (ACS) are an effective intervention for hospitalized patients with substance use disorders (SUD); however, their effectiveness for patients discharged from the emergency department (ED) is not well established. We aim to examine the association of ACS with 30-day engagement in outpatient treatment among ED and hospitalized patients at a multi-hospital safety-net health system. Methods: We conducted a retrospective study of patients discharged after ED and inpatient visits with SUD-related diagnoses. The exposure of interest was receipt of ACS consultation during an ED or inpatient encounter. We used propensity score matching with frequency weights for the analyses, and the primary outcome was engagement in outpatient SUD treatment within 30 days of ED or hospital discharge. Propensity-weighted logistic regression with and without a moderation analysis examined factors associated with engagement in treatment after discharge. Results: From April 1, 2024, through February 28, 2025, 4779 unique patients were discharged with a qualifying SUD diagnosis; 2783 (58.2%) after ED discharge and 1996 (41.8%) after hospital discharge, and 1279 (26.8%) received a Bridge ACS consultation. The 30-day engagement in treatment after discharge rate was 32.6% with ACS versus 9.4% without ( P <0.001). ACS was independently associated with higher odds of engagement [adjusted odds ratio (aOR): 4.7, 95% CI: 3.5–6.4]. The interaction term between ACS and ED versus hospital discharge was not statistically significant (aOR: 0.9, 95% CI: 0.5–1.5). Conclusions: ACS consultation was associated with increased engagement in SUD treatment within 30 days of ED or hospital discharge.

Objectives: Healthcare Effectiveness Data and Information Set (HEDIS) measure Follow-up After Emergency Department Visit for Substance Use (FUA) assesses care coordination after discharge from an emergency department visit for a high-risk substance-use event. We hypothesized that the FUA denominator undercounts OUD-related ED visits. Methods: We audited a multihospital public health system’s electronic health record (EHR) to identify ED visits by patients with OUD to compare these with the OUD visits captured in the system’s automated FUA reporting. Results: From April 1, 2024, through February 28, 2025, there were 1211 emergency department (ED) unique visits related to opioid use disorder (OUD) or overdose. Only 239 (19.7%) of OUD/overdose encounters were using HEDIS methods for FUA. In multivariable logistic regression, ED visits at one of the hospitals were less likely to be included in the FUA measure (adjusted odds ratio, 0.6, 95% CI: 0.4–0.9). Conclusions: We found the FUA measure failed to identify 4 out of 5 ED visits involving high-risk opioid use disorder–related events. This suggests FUA may obscure quality performance and introduces variability into the national quality measure.

Author(s): Mukau, Leslie; Wormley, Kadia; Tomaszewski, Christian; Ahmad, Bushra; Vohra, Rais; Herring, Andrew A.

In 2021, opioid use disorder (OUD) contributed to more than 80 000 overdose deaths in the US, up 24% from 2020.¹ More than 5% of overdose patients seen at an emergency department (ED) die within the year, many in the first 2 days after discharge.^2,3 The scale and persistence of the OUD epidemic is increasing the urgency to integrate screening and treatment for OUD into mainstream emergency medicine practice.⁴ Emergency departments are uniquely positioned to contribute toward improved care at all stages of the OUD treatment cascade,⁵ particularly by improving access to medication for OUD, such as buprenorphine, through direct administration or prescription. Buprenorphine treatment of OUD improves quality of life and reduces both overdose risk and mortality. Additionally, buprenorphine decreases high-risk behaviors linked to transmission of HIV and hepatitis C.⁶ Despite the many well-established benefits of buprenorphine treatment for OUD, adoption in most EDs remains limited.

Background: Optimal treatment of buprenorphine precipitated opioid withdrawal (BPOW) is unclear. Full agonist treatment of BPOW is limited by buprenorphine’s high-affinity blockade at mu-opioid receptors (μORs). Buprenorphine’s partial agonism (low intrinsic efficacy) at μORs can limit the effectiveness of even massive doses once BPOW has begun. Adjunct medications, such as clonidine, are rarely effective in severe BPOW. Ketamine is an N-methyl-D-aspartate receptor antagonist with a potentially ideal pharmacologic profile for treatment of BPOW. Ketamine reduces opioid withdrawal symptoms independently of direct μOR binding, synergistically potentiates the effectiveness of buprenorphine μOR signaling, reverses (resensitizes) fentanyl induced μOR receptor desensitization, and inhibits descending pathways of hyperalgesia and central sensitization. Ketamine’s rapid antidepressant effects potentially address depressive symptoms and subjective distress that often accompanies BPOW. Ketamine is inexpensive, safe, and available in emergency departments. To date, neither ketamine as treatment for BPOW nor to support uncomplicated buprenorphine induction has been described. Case Description: We report a case of an illicit fentanyl-using OUD patient who experienced severe BPOW during an outpatient low-dose cross taper buprenorphine induction (ie, “microdose”). The BPOW was successfully treated in the emergency department with a combination of ketamine (0.6 mg/kg intravenous over 1 hour) combined with high-dose buprenorphine (16 mg sublingual single dose); 3 days later he was administered a month-long dose of extended-release subcutaneous buprenorphine which was repeated monthly (300 mg). At 90 days the patient remained in treatment and reported continuous abstinence from fentanyl use. Conclusions: This single case observation raises important questions about the potential therapeutic role of ketamine as a treatment for BPOW. BPOW is an important clinical problem for which there is currently only limited guidance and no universally accepted approach. Prospective study comparing the effectiveness of differing pharmacologic approaches to treat BPOW is urgently needed.

Initiation of buprenorphine for the treatment of opioid use disorder (OUD) in the emergency department (ED), combined with linkage to outpatient care, is an effective strategy to reduce mortality and morbidity among persons living with opioid addiction.^1,2 With a total of 50 042 lives lost in 2019 because of opioid overdose deaths, projections of a 30% increase in 2020, and evidence that ED-initiated buprenorphine is both life-saving and cost-effective, the American College of Emergency Physicians, the US Surgeon General, the National Institute of Drug Abuse, and the Substance Abuse and Mental Health Services Administration have all called for ED access to initiation of buprenorphine for treatment of OUD.^3-6 Yet, patients frequently face substantial barriers to obtaining buprenorphine in a timely manner after ED discharge because of a lack of ED clinicians with US Drug Enforcement Agency X-waivers permitting them to prescribe buprenorphine or other logistical issues in filling prescriptions associated with prior authorization requirements, transportation, and health insurance coverage gaps.^7-11