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Introduction: Overdose deaths from high-potency synthetic opioids, including fentanyl and its analogs, continue to rise along with emergency department (ED) visits for complications of opioid use disorder (OUD). Fentanyl accumulates in adipose tissue; although rare, this increases the risk of precipitated withdrawal in patients upon buprenorphine initiation. Many EDs have implemented medication for opioid use disorder (MOUD) programs using buprenorphine. However, few offer methadone, a proven therapy without the risk of precipitated withdrawal associated with buprenorphine initiation. We describe the addition of an ED-initiated methadone treatment pathway and compared its 72-hour follow-up outpatient treatment engagement rates to our existing ED-initiated buprenorphine MOUD program. Methods: We expanded our ED MOUD program with a methadone treatment pathway. From February 20–September 19, 2023, we screened 20,504 ED arrivals; 5.1% had signs of OUD. We enrolled 61 patients: 28 in the methadone; and 33 in the buprenorphine pathways. For patients who screened positive for opioid use, shared decision-making was employed to determine whether buprenorphine or methadone therapy was more appropriate. Patients in the methadone pathway received their first dose of up to 30 milligrams (mg) of methadone in the ED. Two additional methadone doses of up to 40 mg were dispensed at the time of the ED visit and held in the department, allowing patients to return each day for observed dosing until intake at an opioid treatment program (OTP). We compared 72-hour rates of outpatient follow-up treatment engagement at the OTP (for those on methadone) or at the addiction treatment center (ATC) (for those on buprenorphine) for the two treatment pathways. Results: Of the 28 patients enrolled in the methadone pathway, 12 (43%) successfully engaged in follow-up treatment at the OTP. Of the 33 patients enrolled in the buprenorphine pathway, 15 (45%) successfully engaged in follow-up treatment at the ATC (relative risk 1.06; 95% confidence interval 0.60–1.87). Conclusion: Methadone initiation in the ED to treat patients with OUD resulted in similar 72-hour follow-up outpatient treatment engagement rates compared to ED-buprenorphine initiation, providing another viable option for MOUD.

Abstract Objectives For successful Naloxone Leave Behind (NLB) programs, Emergency Medical Services (EMS) must identify patients at‐risk for opioid overdose. We describe the first year of Vermont's NLB program and report rates of EMS documentation of at‐risk patients with subsequent distribution of NLB kits in the subgroup of those refusing transport to an emergency department (ED). Methods This retrospective cohort review of all EMS encounters over 1 year compared on‐scene EMS documented to retrospective chart reviewidentified at‐risk patients eligible for NLB kit dispersal. EMS was educated to identify at‐risk patients through statewide mandatory training modules. At‐risk patients were identified by electronic chart review using the same training criteria. As per protocol, patients identified as at‐risk by EMS who refuse ED transport are eligible for NLB. NLB‐appropriate patients by retrospective chart review without NLB protocol use documentation by EMS were considered “missed.” Results Of 110,701 EMS encounters, 2507 (2.4%) were at‐risk by chart review. Among these, 793 refused transport to an ED. In this chart‐review at‐risk non‐transported group, EMS documented 407 (51.3%) patients as at‐risk by documenting use of the NLB protocol. Of these 407, EMS provided 141 (34.6%) with NLB kits. Fifteen (3.7%) patients refused kits. There were 386 (48.7%) potentially “missed” opportunities for NLB dispersal. Conclusion EMS documented 51.3% of patients eligible for NLB dispersal, with 34.6% receiving kits. There was no documentation for 48.7% of chart‐review at‐risk patients, suggesting “missed” distribution opportunities. This study highlights the need for improved EMS identification of at‐risk patients, EMS documentation adherence, and NLB kit provision.

Abstract Objective Start Treatment and Recover (STAR) is an emergency department (ED) program that expands access to medication for opioid use disorder by identifying patients with opioid use disorder and offering ED‐initiated buprenorphine/naloxone and rapid access to outpatient treatment. We sought to determine the impacts of the coronavirus disease 2019 pandemic on STAR and the patients with opioid use disorder it serves. Methods We conducted a retrospective review of records comparing 2 periods: pre‐pandemic (February 1, 2019–February 29, 2020) and pandemic (March 1, 2020–May 31, 2020). Variables evaluated included the number of STAR enrollments, ED census, percentage of census screening positive for opioid use disorder, number and percentage of ED overdose visits, and overdose fatalities by month. All analyses were conducted using 2‐sample t tests to calculate the mean and 95% confidence intervals (CIs). Results Comparing the pre‐pandemic to the pandemic period, the mean monthly ED visits decreased from 5126.9 to 3306.7 (difference = −1820.3; 95% CI, −3406.3 to −234.2), STAR mean monthly enrollments decreased from 9.7 to 1.3 (difference = −8.4; 95% CI, −12.8 to −4.0), and statewide monthly opioid‐related fatalities increased from 9.4 to 15.3 (difference = 5.9; 95% CI, 0.8 to 11.1). However, the percentage of individuals who presented to the ED with opioid use disorder or overdose remained unchanged. Conclusion Although overall ED visits declined during the pandemic period, the percentage of patients presenting with opioid use disorder or overdose remained constant, yet there was a dramatic decline in enrollment in ED‐initiated medication for opioid use disorder and an increase in statewide monthly opioid‐related fatalities. Strategies to maintain medication for opioid use disorder treatment options must be implemented for this vulnerable population during the ongoing pandemic.