Emergency Department–Initiated Buprenorphine: National Trends and Disparities, 2017–2024

Emergency department (ED)–initiated buprenorphine reduces mortality and improves retention for opioid use disorder (OUD), yet uptake remains limited. This study characterizes national trends and predictors of implementation using a large, multi-payor dataset.

We conducted a retrospective observational study using the Institute for Health Equity Research Multi-Payor Claims Database (2017–2024). We identified adult ED visits for OUD, overdose, or injection drug use (IDU)–related infections among commercially insured, Medicare Advantage, and Medicaid beneficiaries. The primary outcome was ED-initiated buprenorphine (administration or pharmacy fill within 7 days). To capture de novo initiation, we excluded inpatient admissions and patients with MOUD claims in the preceding 30 days. Multivariable logistic regression estimated adjusted odds ratios (aOR) for key predictors.

We identified 331,694 eligible visits among 303,866 adults. In 2017, 6.9% of visits involved buprenorphine, increasing to 17.6% in 2024. Non-Hispanic Black (aOR 0.85, 95% CI 0.82–0.88), Non-Hispanic Asian (aOR 0.82, 95% CI 0.70–0.95), and Hispanic (aOR 0.93, 95% CI 0.90–0.96) patients had lower odds of receiving buprenorphine compared with Non-Hispanic White patients. Medicare Advantage patients (aOR 0.92, 95% CI 0.86–0.99) were less likely to receive treatment vs. commercial insurance; no significant difference was observed for Medicaid (aOR 0.98, 95% CI 0.94–1.02). Non-metropolitan EDs had marginally higher initiation odds vs. metropolitan (aOR 1.04, 95% CI 1.01–1.08). Clinical presentation was the strongest predictor; compared to non-fatal overdose, OUD diagnoses (aOR 8.11, 95% CI 7.76–8.47) and IDU-related infections (aOR 3.81, 95% CI 3.49–4.14) had higher odds of initiation.

While ED-initiated buprenorphine has grown, overall use remains low with significant racial/ethnic disparities. Acute overdose presentations represent a critical missed opportunity. Equitable access remains a gap for Black, Asian, and Hispanic patients.