Rebellion in EM 2019: Suboxone for Opioid Addiction via Salil Bhandari, MD

Background: The role of the ED physician in helping stop the opioid epidemic is three-fold: safe prescribing practices, beginning suboxone administration in the ED as part of an ED/Community Suboxone program, and providing Narcan prescriptions to at risk patients. Most ED physicians are not doing the latter two.

Rebellion in EM 2019: Suboxone for Opioid Addiction via Salil Bhandari, MD


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Suboxone for Opioid Addiction

  • Past treatments for opioid addiction do not work including addiction therapy, detox centers, methadone, and naltrexone

Critical Point #1: Opioid addiction is not a moral failing but a chronic disease that needs medical assistance in order to treat, and Suboxone is the treatment

  • Suboxone is a combination of buprenorphine (a partial agonist at mu-opioid receptor that replacing opioids being abused) and naloxone (a mu-opioid antagonist only active if injected IV whose sole purpose is to prevent abuse)
  • Suboxone has a ceiling for its respiratory depression and euphoric effects
  • Suboxone should be initiated in the ED because that’s where the patients are!

Critical Point #2: Suboxone MUST be initiated when patients are in mild to moderate withdrawal, otherwise it’s administration will precipitate a withdrawal.

  • You do not need an X-waiver to administer a dose of Suboxone in the ED for acute withdrawal, only to write a prescription for it

Critical Point #3: After administration of suboxone in the ED patients MUST be referred to an outpatient community program that can continue prescribing suboxone to the patient

  • Patients taking suboxone have longer treatment retention and longer abstinence from opioid abuse


  1. To Obtain an X-Waiver: Provider’s Clinical Support System for Medication-Assisted Treatment (PCSS-MAT) [Link is HERE]
  2. D’Onofrio G et al. Emergency Department–Initiated Buprenorphine/Naloxone Treatment for Opioid Dependence: A Randomized Clinical Trial. JAMA 2015. PMID: 28194688
  3. Larochelle MR et al. Medication for Opioid Use Disorder After Nonfatal Opioid Overdose and Association With Mortality: A Cohort Study. Ann Intern Med 2018. PMID: 29913516
  4. Herring AA et al. Managing Opioid Withdrawal in the Emergency Department with Buprenorphine. Annals of Emergency Medicine  2019. PMID: 30616926

Post Peer Reviewed By: Salim R. Rezaie, MD (Twitter: @srrezaie)

Cite this article as: Salim Rezaie, "Rebellion in EM 2019: Suboxone for Opioid Addiction via Salil Bhandari, MD", REBEL EM blog, January 23, 2020. Available at:
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Salim Rezaie

Emergency Physician at Greater San Antonio Emergency Physicians (GSEP)
Creator & Founder of REBEL EM

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