Training Paramedics to Administer Buprenorphine in the Field

Write-up by IRIS team members: Victoria Barreira & Yali Deng

Emergency medical services (EMS) teams can play a crucial role in quickly intervening during an overdose by initiating medication for opioid use disorder (MOUD), as they are often the first point of contact for individuals experiencing an opioid overdose. In addition, delivering MOUD in the pre-hospital setting is important to reach a high-risk population considering that many patients who experience overdose decline emergency department transport.

In February 2025, House Bill 1131, titled Public Health - Buprenorphine - Training Grant Program and Workgroup was introduced in Maryland. This bill proposes to establish the Buprenorphine Training Grant Program to help counties with the expense of training paramedics to administer buprenorphine. This bill outlines the following details: "including Program as an authorized use of funding from the Opioid Restitution Fund; requiring the Governor to include in the annual budget bill an appropriation of at least $50,000 from the Opioid Restitution Fund for the Program; and requiring the Maryland Office of Overdose Response to convene a workgroup to study access to buprenorphine in the State”.

According to a scoping review of the relevant literature (Joiner et al., 2025), there are 9 published evaluation studies of EMS- buprenorphine programs, covering five programs across four states. In this research corner, we summarize two research articles that examined the effectiveness of initiating buprenorphine by a trained EMS team. The first article presents the first-year results of a pilot program in California, followed by a second retrospective cohort study conducted in an urban New Jersey community.

Article 1

"Prehospital Buprenorphine Treatment for Opioid Use Disorder by Paramedics: First Year Results of the EMS Buprenorphine Use Pilot"

Hern, H. G., Lara, V., Goldstein, D., Kalmin, M., Kidane, S., Shoptaw, S., Tzvieli, O., & Herring, A. A. (2023). Prehospital Buprenorphine Treatment for Opioid Use Disorder by Paramedics: First Year Results of the EMS Buprenorphine Use Pilot. Prehospital Emergency Care, 27(3), 334–342. https://doi.org/10.1080/10903127.2022.2061661

This article presents first-year results of an EMS Buprenorphine Use Pilot Program in Contra Costa County, California. This program was designed to integrate EMS into a multi-pronged public health approach for opioid use disorder (OUD) treatment. It consists of four interventions: (1) public access naloxone distribution, (2) an electronic trigger and data sharing program to track and reach out to high-risk patients, (3) a designated overdose receiving center (ORC) with specialized OUD treatment resources and personnel, including navigators, and (4) paramedic-initiated buprenorphine treatment following a structured protocol. If a patient meets the eligibility and expresses interest in buprenorphine treatment, a paramedic can administer buprenorphine in the field after consulting with an on-call physician. The paramedics will then recommend transport to an ORC for further treatment. In the ORC, treatment navigators will contact the patient within 1-2 days to offer additional outpatient treatment regardless of whether they receive buprenorphine or not. The electronic trigger system enables data sharing between EMS agencies and public health agencies. The navigator also tracks patients (who received buprenorphine) for clinical outcomes and treatment engagement at 7 and 30 days.

In the first year of initiation, 36 patients received buprenorphine in the field. All patients, except one who declined, were transported to the emergency department, including 75% who were transported to a designated ORC and 25% to a non-ORC. Follow-up data showed that none of the patients experienced precipitated withdrawal, and all showed either improvement or no change in their withdrawal symptoms. Half of the 36 patients remained in treatment at 7 days, and 36% remained in treatment at 30 days. Notably, patients transported to ORCs had higher treatment retention than those transported to non-ORC sites (41% vs. 25% in treatment at 30 days). However, Black patients had lower treatment retention compared to White patients (11% or 1 out of 9 vs. 52% or 12 out of 23 in treatment at 30 days). Though authors did not provide possible explanations, research from Mennis et al. (2019) indicated that economic disadvantage and greater social needs such as employment, housing, and legal made it harder to engage patients from racial minority backgrounds in treatment. They found that neighborhood characteristics and limited access to community treatment may also contribute to this inequity.

In conclusion, this pilot paramedic-initiated treatment showed promising results in reducing withdrawal symptoms and engaging patients in treatment. The authors pointed out that additional outreach and follow-up programs (e.g., data sharing systems and navigators) are important to complement this paramedic-initiated buprenorphine program to better connect people to long-term care. These findings suggest that reaching high-risk population and getting them to initiate MOUD is encouraging, but only a part of long-term comprehensive support. More research and programs are also needed to address barriers to community-based care for Black Americans.

Article 2

"Impact of Administering Buprenorphine to Overdose Survivors Using Emergency Medical Services"

Article 2: Carroll, G., Solomon, K. T., Heil, J., Saloner, B., Stuart, E. A., Patel, E. Y., Greifer, N., Salzman, M., Murphy, E., Baston, K., & Haroz, R. (2023). Impact of Administering Buprenorphine to Overdose Survivors Using Emergency Medical Services. Annals of Emergency Medicine, 81(2), 165–175. https://doi.org/10.1016/j.annemergmed.2022.07.006

This article evaluated the efficacy of administering buprenorphine by an EMS team in an urban community in New Jersey. Similar to the program in the first article, trained paramedics conducted assessments for on-site buprenorphine treatment after an overdose resuscitation, discussed the case with an EMS physician, and administered buprenorphine if patients were eligible. If patients received buprenorphine, they were also scheduled for a same or next business day substance use disorder clinic appointment.

This is a retrospective comparison study between two matched cohorts, i.e., comparing outcomes between patients who received care from buprenorphine-equipped ambulances with those who received standard EMS care. The dispatch of EMS was based on the proximity and availability of an ambulance and did not prioritize buprenorphine-equipped ambulances for suspected opioid overdose encounters. This assignment of ambulance provides a natural experimental condition, which means patients who encountered a buprenorphine-equipped ambulance or non-buprenorphine-equipped ambulance were approximately random. The authors also compared individuals who received buprenorphine in the field and those who were offered but did not receive buprenorphine in the field. The authors used a matching procedure to select the sample, which included 94 patients who received buprenorphine in the field (group 1A), a random sample of 100 patients who encountered a buprenorphine-equipped ambulance but not receive buprenorphine (group 1B), and a matched sample of 194 patients who encountered a non-buprenorphine equipped ambulance based on age, sex, and race/ethnicity (control group). After the exclusion of incomplete information, the final sample included 74 in group 1A, 43 in group 1B and 123 in the control group. The outcomes of interest in this study were opioid withdrawal symptoms, subsequent overdoses (i.e., overdoses within 24 hours and 7 days of the encounter), and outpatient follow-up rates (i.e., post-overdose clinic visits within 30 days).

This study found that patients who encountered a buprenorphine-equipped ambulance were more likely (almost a 6-fold increase) to engage in treatment within 30 days post-overdose compared to non-buprenorphine-equipped ambulance cases. However, both groups had similar 24-hours and 7-days overdose rates. The comparison between group 1A and 1B showed similar results. Patients who received buprenorphine showed higher odds of 30-days treatment engagement and comparable subsequent overdose rates compared to patients who were offered but refused buprenorphine. This study also found that patients treated with buprenorphine reported decreased withdrawal symptoms (clinical opiate withdrawal score decreased from 9.27 to 3.16). Buprenorphine administration increased on-scene EMS time by 6.12 minutes on average.

The study concludes that EMS-initiated buprenorphine treatment effectively reduced withdrawal symptoms and encouraged follow-up treatment engagement without increasing overdose risk.

Conclusion

This research corner reviewed Maryland House Bill 1131 and two recent articles that examined the efficacy of EMS-initiated buprenorphine treatment. Both studies indicate that this intervention is promising to reach a high-risk population and engage them in OUD treatment. It is important to note that both programs introduced in the articles involve 1-2 days follow-up and treatment referrals. The scoping review cited earlier indicates that programs with warm hand-offs and follow-up care showed higher rates of treatment retention (Joiner et al., 2025). To maximize benefit, in addition to training paramedics, EMS teams should develop partnerships with local outpatient treatment providers and develop a warm-handoff process to ensure continued care.

References

Joiner, A. P., Wanthal, J., Murrell, A. N., Cabañas, J. G., Carroll, G., Hern, H. G., Sasser, M., Poland, C., Mercer, M. P., & Glenn, M. (2025). A scoping review and consensus recommendations for Emergency Medical Services Buprenorphine (EMS-Bupe) Programs. Prehospital Emergency Care, 1–23. https://doi.org/10.1080/10903127.2024.2445739

Mennis, J., Stahler, G. J., Abou El Magd, S., & Baron, D. A. (2019). How long does it take to complete outpatient substance use disorder treatment? Disparities among Blacks, Hispanics, and Whites in the US. Addictive behaviors, 93, 158-165. https://doi.org/10.1016/j.addbeh.2019.01.041