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Methadone Initiation in the Emergency Department for Opioid Use Disorder: A Case Series

  • Samantha Huo
    Correspondence
    Corresponding Author: Samantha Huo, 501 S. 54th Street, Philadelphia, PA 19143
    Affiliations
    Cooper University Health Care, Center for Healing, Division of Addiction Medicine, Camden, NJ

    Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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  • Jessica Heil
    Affiliations
    Cooper University Health Care, Center for Healing, Division of Addiction Medicine, Camden, NJ
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  • Matthew S. Salzman
    Affiliations
    Cooper University Health Care, Center for Healing, Division of Addiction Medicine, Camden, NJ

    Cooper Medical School of Rowan University, Camden, NJ

    Cooper University Health Care, Department of Emergency Medicine, Division of Addiction Medicine and Medical Toxicology, Camden, NJ
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  • Gerard Carroll
    Affiliations
    Cooper University Health Care, Department of Emergency Medicine, Division of Addiction Medicine and Medical Toxicology, Camden, NJ

    Cooper University Health Care Department of Emergency Medicine, Division of EMS and Disaster Medicine, Camden, NJ
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  • Rachel Haroz
    Affiliations
    Cooper University Health Care, Center for Healing, Division of Addiction Medicine, Camden, NJ

    Cooper Medical School of Rowan University, Camden, NJ

    Cooper University Health Care, Department of Emergency Medicine, Division of Addiction Medicine and Medical Toxicology, Camden, NJ
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      Abstract

      Background

      In an era of fentanyl and continually rising rates of opioid overdose deaths, increasing access to evidence-based treatment for opioid use disorder (OUD) should be prioritized. Emergency Department (ED) buprenorphine initiation for patients with OUD is considered best-practice. Methadone, though also evidence-based and effective, is under-utilized due to strict federal regulation, significant stigma, and lack of physician training. We describe the novel utilization of CFR Title 21 1306.07 (b), also known as the “72-hour rule”, to initiate methadone for OUD in the ED.

      Case Series

      We describe the cases of three patients with a history of OUD who were initiated on methadone for OUD in the ED, linked to an opioid treatment program, and attended an intake appointment.

      Why should an emergency physician be aware of this?

      The ED can be a crucial point of intervention for vulnerable patients with OUD who may not interact with the healthcare system in other settings. Methadone and buprenorphine are both first-line options for medication for opioid use disorder, and methadone may be preferred in patients who have been unsuccessful with buprenorphine in the past or those at higher risk of treatment dropout. Patients may also prefer methadone to buprenorphine based on previous experience or understanding of the medications. ED physicians may utilize the “72-hour rule” to administer and initiate methadone for up to three consecutive days while arranging referral to treatment. EDs can develop methadone initiation and bridge programs utilizing similar strategies to those that have been described in developing buprenorphine programs.

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