September 5, 2018

Use of the Emergency Department Observation Unit (EDOU) for Patients with Opioid Use Disorder

Nine months ago, we began an observation protocol for buprenorphine (Suboxone ®) induction in our EDOU. This idea came from our toxicology division, as they were trying to cope with the opioid epidemic and rising opioid-related deaths. This is one phase of treatment for patients with Opioid Use Disorder who present to the ED in early stages of withdrawal with desire to quit using opioids. This protocol was developed in conjunction with our toxicologists.


  • Opioid Use Disorder highly motivated for buprenorphine maintenance
  • Non-suicidal patients
  • Stable vital signs and mental status
  • Toxicology consult obtained in ED, and buprenorphine induction planned


  • Any suicidal ingestion
  • Unstable vital signs, altered mental status, combative, or disruptive patients
  • Abuse of Benzodiazepines or Ethanol
  • Evidence of organ dysfunction
  • Toxicology not consulted


  • IV fluids
  • Opioid withdrawal monitoring using the Clinical Opioid Withdrawal Scale (COWS) (See below) 
  • Labs or drug screens 
  • Symptomatic treatment with clonidine, hydroxyzine, diazepam, and non-opioid analgesics 



  • Stable Vital Signs
  • Patients with low COWS score
  • Patient cleared for discharge by toxicologists.


  • Unstable vital signs
  • Persistent symptoms (vomiting, diarrhea)
  • Significant new lab abnormalities (LFTs, CPK, electrolytes)
  • Admission recommended by medical toxicology

Initial assessment by toxicology includes scoring them for Opioid Use Disorder based on DSM-V criteria and evaluation of withdrawal using the COWS. Additionally, treatment options are discussed, and information about Suboxone and the Medication Assisted Opioid Therapy (MAOT) clinic is provided to the patients. 

If an emergency department patient meets criteria for moderate or severe Opioid Use Disorder and is not in moderate to severe withdrawal, they will be transferred to the Clinical Decision Unit (CDU) for induction. In the CDU, they are given adjunctive medications until their withdrawals progress enough to meet criteria for receiving Suboxone (COWS ≥ 12 or definitive last known opioid use ≥ 12 hours for short acting and ≥ 24 hours for long acting agents).

The Suboxone order is placed by the medical toxicologist who is covering the service. The initial dose is administered by the doctor. The patient is then monitored for 1-2 hours to assess for any precipitated withdrawal symptoms. If their withdrawal symptoms have improved, but not resolved, patients may receive a second dose of buprenorphine up to a maximum first day’s dose of 8 mg, at the discretion of the consulting physician.

Upon discharge, the patient is given a prescription for Suboxone on a case-by-case basis and an appointment to be seen in the MAOT clinic within 1-3 days of hospital discharge. The MAOT clinic is primarily operated with the same medical toxicologists who operate the consultation service. This system ensures continuity of care.

To date, 31 patients have been observed using this protocol. Average LOS in the CDU is 20.6 hours. One patient required hospital admission for concomitant rhabdomyolysis. All patients were given follow-up appointments in the MAOT clinic. Early data shows that 60% of EDOU patients have attended clinic follow-up.

The main pitfall for this protocol so far has been patient selection. One of the exclusion criteria is withdrawal from more than one substance. Patients addicted to opioids often use or abuse other substances, so it is important to screen patients for intoxication/withdrawal of other substances. The second issue involving patient selection involves patients who aren’t given Suboxone once they are seen by toxicology the next morning. We need to review these cases from a quality improvement/quality assessment (QI/QA) perspective and refine the inclusion/exclusion criteria, as needed.

For more information on this protocol, see the Obs protocols site or the Pobscast episode Dr. Osborne and I did on this.

Matthew Wheatley, MD, FACEP