The opioid epidemic has touched the lives of almost every American, either directly or indirectly. Patients who are battling opioid use disorder (OUD) traverse all geographic, political, socioeconomic, racial and cultural demographics.
As such, prehospital providers are all too familiar with OUD. This includes both fatal and non-fatal overdoses. The risk of encountering someone experiencing an overdose is so ubiquitous and deadly that the Federal Substance Abuse Mental Health and Services Administration (SAMHSA) recommends that naloxone be made available in as many public places as possible, including elementary schools [1]. Many times, after an overdose is reversed with naloxone, an acute withdrawal from opioids can occur. The medication buprenorphine (e.g., Suboxone) is newer to the prehospital space in the U.S., but can play a significant role in reducing those withdrawal symptoms and putting patients on a path to long-term recovery.
Early publications on buprenorphine are from pioneers in the field, such as EMS Bridge (California) and Cooper EMS (New Jersey) [2-6]). They describe how prehospital providers can do implement buprenorphine programs safely and how they can impact patients. These include having a 12-fold increased engagement in treatment at 30 days [2].
However, when it comes to making this a reality at any particular EMS service, there are several common barriers described to implementing buprenorphine. Services often worry that the medication is too complicated or risky, there is not sufficient time for training, and there is no comprehensive plan in place to ensure follow-up care.
MORE | How paramedics can open the door to long-term recovery with buprenorphine
Implementing buprenorphine at Hennepin EMS
At Hennepin EMS, where we serve Minneapolis and 13 surrounding communities, we initially had these same concerns, but we knew the benefits for patients made implementing buprenorphine worth pursuing. We discussed possibilities with a multi-disciplinary team of experts who interact with patients battling OUD in various ways, such as:
- Addiction medicine
- Emergency medicine
- EMS
- Internal medicine/primary care
- Toxicology
Ultimately, we were able to develop a program that was safe, simple and workable for our frontline providers. In the first year, we had 121 administrations with no patients developing worsening symptoms, no repeat EMS visits for overdose (OD) within 24 hours, and at least 11 patients in sustained treatment at 30 days.
At Hennepin EMS, administering buprenorphine is not treated as a special skill, but rather an advanced life support (ALS) medication that comes with specific training — just like any other [3]. We have trained all our 185 paramedics and put buprenorphine on all 40 of our ambulance rigs so that it can be administered on-scene, in real-time, without any need for medical direction contact or telehealth. We established the following protocol that wasn’t overwhelming or overly complicated to be completed on-scene (the most current version can be found at protocols.hennepinems.net):
A serious concern during protocol development was that administration of buprenorphine prehospital might precipitate worsened opioid withdrawal symptoms. Over time, we have gained more insight into the actual rate of precipitated withdrawal, which has been shown to be less than 1% after reviewing hundreds of patients [4-6]. At Hennepin, we were able to show that our protocol is equally safe with no patients having worsened symptoms after receiving buprenorphine.
Buprenorphine training
When considering the training time required, many EMS medical directors think back to the 8-hour day that accompanied the X-waiver of the early 2000s that has since been eliminated [7]. When focusing on the most important skills and information for prehospital providers, we trained our paramedics with a focused lecture/discussion that totals about 35 minutes in length. This prevented it from becoming overly burdensome for the paramedics and allowed us to work it into our semi-annual training sessions. The following are the key points that we address in these sessions.
Sharing success
We also were concerned about our patients’ ability to continue buprenorphine after their prehospital administration. Ultimately, we wanted to offer this to our patients even though we couldn’t immediately facilitate a specific follow-up plan at the time of administration. We’ve since heard from our paramedics that often we can treat the symptoms of acute opioid withdrawal, which can start the discussion about ongoing medication for opioid use disorder (MOUD). However, sometimes in a moment of crisis, a robust and thoughtful conversation about long-term therapy isn’t realistic. We worked collaboratively with our hospital partners to improve access and understanding of the clinic system.
With each new initiative, we don’t expect perfection and know adjustments will need to be made to overcome barriers within the system. We focused on carefully developing our research-backed protocol and continued to adapt it in collaboration with our hospital and other clinic-based partners. Based on the success we have recorded since implementation, we encourage every service to seriously consider if this is something they could offer their patients. At Hennepin EMS, we have found it to be safe and achievable for the entire service while lowering barriers to care and providing more opportunities for patients with OUD.
REFERENCES
- Naloxone Frequently Asked Questions - Non-Presciption [Internet]. Substance Abuse and Mental Health Services Administration; 2023 [cited 2025 Feb 11]. Available from: https://www.samhsa.gov/substance-use/treatment/overdose-prevention/otc-naloxone-faqs.
- Carroll G, Solomon KT, Heil J, Saloner B, Stuart EA, Patel EY, Greifer N, Salzman M, Murphy E, Baston K, et al. Impact of Administering Buprenorphine to Overdose Survivors Using Emergency Medical Services. Ann Emerg Med. 2023;81:165–175. Cited: in: : PMID: 36192278.
- Simpson NS, Kummer TM, Drone HM, Perlmutter MC, Schin AM, Cole JB, Driver BE, Puskarich MA, Martin ME, Bunting AJ, et al. Feasibility and safety of a paramedic-directed prehospital buprenorphine initiation protocol for acute opioid withdrawal. Prehosp Emerg Care. 2024;0:1–8.
- Hern HG, Goldstein D, Kalmin M, Kidane S, Shoptaw S, Tzvieli O, Herring AA. Prehospital Initiation of Buprenorphine Treatment for Opioid Use Disorder by Paramedics. Prehosp Emerg Care. 2022;26:811–817. Cited: in: : PMID: 34505820.
- Carroll GG, Wasserman DD, Shah AA, Salzman MS, Baston KE, Rohrbach RA, Jones IL, Haroz R. Buprenorphine Field Initiation of ReScue Treatment by Emergency Medical Services (Bupe FIRST EMS): A Case Series. Prehosp Emerg Care. 2021;25:289–293. Cited: in: : PMID: 32208945.
- EMS Bridge Impact Report for April 2024 [Internet]. bridgetotreatment.org. Bridge to Treatment; 2024 [cited 2024 Jul 1]. Available from: https://bridgetotreatment.org/addiction-treatment/ems-bridge/.
- Waiver Elimination (MAT Act) [Internet]. Substance Abuse and Mental Health Services Administration; 2024 [cited 2025 Feb 13]. Available from: https://www.samhsa.gov/substance-use/treatment/statutes-regulations-guidelines/mat-act.
