Rapid Transition From Naloxone Infusion to Sublingual Buprenorphine in the Emergency Department

Since 2024 our Emergency Department (ED) has been transitioning patients with an opioid overdose from continuous naloxone infusions to sublingual buprenorphine. Naloxone infusions treat opioid-induced respiratory depression when opioid toxicity persists despite multiple naloxone boluses. Once a naloxone infusion is started, there is little evidence to guide their management. Buprenorphine, typically used for treatment of opioid use disorder, has been theorized as a long-acting reversal agent due to its competitive partial agonism. In this retrospective cohort study, we compared patients who received isolated naloxone infusions to those who transitioned from naloxone to sublingual buprenorphine with a primary endpoint of admission rates and length of stay.

We queried our electronic medical record for adult ED naloxone infusions from 2024-2025 and manually performed chart review to create buprenorphine and naloxone only cohorts. We enrolled 83 patients, 59 in the naloxone only group and 24 of which were transitioned to buprenorphine. The primary objective compared hospital admission rates using chi-square testing. Secondary objectives included hospital length of stay, ED visits within 48 hours, and follow up rates at one month after ED visit.

All patients met the inclusion criteria of age over 18, and infusion initiated in the ED. The median age was 40 and 81% were male. Hospital admission occurred in 50% of the naloxone only group and 38% in the buprenorphine group (chi squared 1.07, p=0.3). Median difference in length of stay was 4.5 hours (95% CI: 0 - 10.5 hours). Rate of ED visits in 48 hours was 7% in the naloxone only group and 8% in the buprenorphine group (chi squared 0.05, p=0.82). Follow up rates were 7% in the naloxone only group and 17% in the buprenorphine group (chi squared 1.8, p= 0.17). Rates of buprenorphine prescription at discharge were 4% in the naloxone only group and 38% in the buprenorphine group (chi squared 16.6, p <.01).

In patients with an opioid overdose requiring naloxone infusion, transition to sublingual buprenorphine was not associated with a statistically significant decrease in rates of admission, but was associated with shorter lengths of stay and increased rates of buprenorphine prescription on discharge. There was no difference in repeat ED visits in 48 hours, suggesting that this method is comparable in safety to standard naloxone management.