WASHINGTON — In a potential paradigm shift for addiction medicine, New Jersey’s health commissioner this week authorized paramedics to administer the drug buprenorphine to patients almost immediately after reviving them from an opioid overdose.
Paramedics would offer patients the drug, often referred to by the brand name Suboxone, after their overdose had been reversed using the opioid antidote naloxone. The first-in-the-nation model has a twofold purpose, health officials said: Beyond treating the withdrawal symptoms that can result from a naloxone revival, administering buprenorphine on scene could serve as an immediate transition to longer-term treatment.
The bold program is without precedent in the U.S., but serves as a testament to many states’ increasingly aggressive and innovative efforts to reduce drug overdose deaths. And while the announcement came as a surprise to many addiction experts, most applauded the effort.
The buprenorphine, which effectively binds to the same brain receptors as opioids used for pain, would provide a “softer landing” for patients recovering from overdose, said Dr. Dan Ciccarone, a University of California, San Francisco, professor who studies heroin use and the opioid epidemic.
“This comes out of left field, and it’s very interesting,” he said. “It’s a potentially brilliant idea.”
As one of just three medications approved to treat opioid use disorder, buprenorphine has become a centerpiece of addiction treatment efforts nationwide.
While the medication is shown to be highly effective in reducing overdose deaths and illicit drug use, it is an opioid and is therefore regulated as a Schedule III substance by the Drug Enforcement Administration.
Medical practitioners with licenses to prescribe controlled substances must undergo a separate training ranging from eight to 24 hours to prescribe buprenorphine, making New Jersey’s decision to place the drug in paramedics’ hands all the more noteworthy.
“Here we are basically suggesting that we’re going to treat the person in as well-meaning and patient-centric a manner as possible,” Ciccarone said. “And that means naloxone plus a softer landing with buprenorphine.”
Other countries — France, most notably — have dramatically reduced overdose deaths amid a drug crisis by deregulating buprenorphine.
Addiction physicians and medical groups in the U.S. have increasingly advocated for that level of deregulation, including a member of Congress who introduced legislation this year that would allow any licensed prescriber to provide the drug.
Already, doctors in numerous emergency departments have begun to prescribe buprenorphine in an effort to provide instant treatment after reversing an overdose. Extending that ability to paramedics, however, is a new frontier.
As a safeguard, New Jersey’s 1,900 paramedics will need to obtain permission from the emergency physician overseeing their unit before administering buprenorphine when responding to an overdose call. The supervising physician must have a DEA waiver to prescribe buprenorphine, a spokeswoman said.
The order from Dr. Shereef Elnahal, New Jersey’s health commissioner, authorizes only paramedics in the state’s 21 mobile intensive-care units to carry Suboxone or a generic equivalent.
“Buprenorphine is a critical medication that doesn’t just bring folks into recovery – it can also dampen the devastating effects of opioid withdrawal,” Elnahal said in a statement. “That’s why equipping our EMS professionals with this drug is so important.”
As a first-in-the-nation model, the New Jersey approach to overdose response has raised some questions among addiction treatment experts: most notably, patient consent.
Obtaining permission from individuals experiencing withdrawal pain — some in a state of semi-consciousness — to administer buprenorphine could prove challenging, said James Langabeer, a researcher with a focus in addiction medicine at the University of Texas Health Science Center at Houston.
“These are not conversations that are easy to have for anybody, and especially for a paramedic,” Langabeer said, noting the short window between responding to a 911 call and a hospital drop-off. “There’s a whole set of decision-making processes that the paramedic will have to integrate into their protocol.”
It is also unclear whether cost will prove an obstacle to patients beginning treatment. While buprenorphine is generally inexpensive, New Jersey’s health department said in its release that patients given buprenorphine would be billed according to their insurance, in the same manner as patients are billed when paramedics administer drugs to treat asthma attacks or insulin shock.
Most importantly, Langabeer said, the new program will only prove effective in stemming overdose deaths if patients are connected to longer-term treatment almost immediately.
“It’s a really positive first step — but the next step is the next day,” Langabeer said. “They’ve got to be linked to continuing treatment.”
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Is no body going to mention precipitated withdrawal? You have to wait 18-24 hours after the last dose of heroin before you can even begin to think about taking buprenorphine or Suboxone. Most of the overdoses in NJ today are from fentanyl and it is so strong that after people are hit with Narcan they are still high when they wake up, they are not even sick like they would be if it was just a regular heroin overdose. What that means is there is no way any addict on the street is going to say yes they want a suboxone, knowing it is going to make them sick.
Thank you! Wow
Do they understand the chemistry of the brain? Stupid. . . Why? In regards to the mu agonistic vs antagonistic properties of these two situations are very complex. Saving someone then throwing them into full blown, agonizing precipated withdrawal is just going to make the situation worse. An OD is the overabundance of mu-AGONIST , typically short-acting (with half lives less than 6 hours, ex’s. Morphine, heroin, fentanyl, hydrocodone, oxycodone, hydromorphone) vs long acting ones (methadone, OxyContin (unchewed, taken correctly “po” by mouth) … First, all you know that buprenorphine is a partial mu antagonist. (Ex. Subutex or bupinorphine alone) Suboxone is a partial mu antagonist combined with naloxone, a full mu opioid blocker! A person has to be in moderate to severe withdrawal before they can be given either! This is a very stupid thing to do. Learn basic pharmacology & very basic neuroscience. You cannot immediately administer a partial mu antagonist or partial mu antagonist combined with an mu blocker to someone who has OD’d bc OD is an overabundance of a usually short acting mu full blown agonist. It puts the patient in precipated withdrawal! The longer you wait AFTER taking a full on mu opioid agonist is best for treatment bc the patients have to remove the opioid from their system’s for a certain amt of hours, days for long acting opioids before you can introduce a partial mu agonist or one combined with the blocker.
That’s exactly why the whole rest of the country ONLY administers naloxone, the blocker by IV. It wears off & the patient is revived without being thrown into full blown agonizing opiate withdrawal! Terrible idea. Also know that for pain, ALL known opiates beginning with it’s source , opium , from the opium poppy meds are mu agonists , coupled with the fact that their 1st intended purpose is severe pain alleviation. How long do you want someone now, in agonizing opiate withdrawal & in pain to wait b4 they can receive meds. Learn these words 1st NJ : * agonist vs antagonist (a partial antagonist is STILL an antagonist) * a blocker administered by IV wears off rapidly. Sublingually, not so much.
How wonderful, buprenorphine makes recovery possible for many people. My hope is that efforts like these are initiated across the country. I hope we have a long acting bupe injectable soon that does not require 7 days of sublingual bupe to offer people in the ED. Offering medication assisted treatment in the ED would “buy” time for people to get plugged into community programs. Mediation assisted treatment is a good option for people who are ambivalent about recovery too. People need assistance to obtain the medications until they are able to cover the costs themselves.
I think we have to start somewhere This can lead to patients actually entering rehab Did anyone know on addict has to be in acutely withdrawal to qualify for detox That means they have to be so sick BEFORE they can even sign themselves in The bupinorphine will Hopefully allow the patient to make the better choice The heroin vs the rehab There are still so many insurance coverage barriers We need to have an open door policy from the ED to Recovery !
To answer your question it is both yes and no but it is mainly no. There are some places that are state funded that will only accept you in their doors once you have begun to go through withdrawal symptoms but they are a dying breed. Most people in treatment right now are there under insurance or states grants from drug court programs funded at the county level and sometimes state. however if a patient wants to use suboxone to detox from heroin or if they just want to use it for suboxone maintenance then they first have to be in withdrawal from opiates like heroin and oxycodone before they take the suboxone. If they take the suboxone to early (less than 18-24hrs) after their last dose of opiates, they will become VERY sick. worse even than if they didn’t take anything and kicked cold turkey. this is due to how the brain and the buprenorphine interact with one another. you can research more about that if you’d like but its not necessary to answer your initial question.
This is great, but what are the next day plans? Most of the patients I Narcan on OD EMS calls are uninsured, or at best on Medicaid. The amount of providers with a waiver to Rx Bupe is small and their waiting lists to see new patients are long. So, we give someone Bupe on scene once, and, then what? I’m a huge fan of Bupe, don’t get me wrong. But I feel there’s a disconnect and until that’s solved, this isn’t the answer.
The patients are given an appointment and services the next day regardless of insurance or ability to pay.
Adding 50 million innocent medical patients to an illicit drug use “epidemic” that they had no part in. Proven by CDCs admissions. Going against the AMA & CDC chronic pain patients are denied life saving pain medications that allow them to escape constant pain from painful diseases and conditions has become a human rights issue of major consequences. Pain patients left in torturous pain commit suicide, suffer medical collapse, or are forced to take illicit drugs. Then the powers that be say see?? we knew you were a addict? anyone see the irony of giving an addict opioids as the treatment for their overdose? yet legitimate medical patients who have painful diseases and conditions and were working, finding relief from their pain are being denied what has often worked for them for decades? Stop allowing the torture of chronic pain of all kinds. Doctors need to speak up to Senators, and regulators because everyone has accused us of being people who need tough love to just yoga our pain away.
Agonist medications to treat opioid use disorder are evidence based life saving medications. There is no irony for people with OUD taking agonists. Now, to address you issue about chronic pain. I don’t think people with chronic pain should suffer at all and they should not be denied pain relieving medications. However, I believe advocating for chronic pain patients should not involve opposing the proven treatment for OUD.
Administering buprenorphine after OD revival is a step in the right direction – one that I assumed would already have long been taken (!). OD treatment needs to be vastly stepped up in addressing the opioid crisis. And those meds ought to be covered by National Health Care, if one is serious about fixing a National Crisis. If not, the crisis will never be solved, simply because the addicts can not pay for getting clean.
Nation Health Care? We’re talking about the US – no such thing.
This is all well and good providing that New Jersey have the availability of physicians who are available to provide continued care for these patients. As a practicing emergency physician, I am witness to the thousands of patients who either have no money or on state Medicaid and can’t find a physician or other provider to continue to prescribe Suboxone. I know of physcains who operate Suboxone clinics on a cash only basis and just provide the monthly prescriptions for $175 a month ($2,100 per year just for the doctor). Others who have no insurance or Medicaid and can’t find providers at all. This paramedic plan is only one SMALL piece in solving the opiate crisis in NEW JERSEY. yes, a novel idea that will make national press but not the final solution. We all know how poorly Medicaid pays providers in NJ and it is a reflection on the care we offer those less fortunate individuals in our society. At the Hubert Humphrey Building dedication, Nov. 1, 1977, in Washington, D.C., former vice president Humphrey spoke about the treatment of the weakest members of society as a reflection of a government: “The moral test of government is how that government treats those who are in the dawn of life, the children; those who are in the twilight of life, the elderly; those who are in the shadows of life, the sick, the needy and the handicapped.”
What is your position on giving Vivitrol since that is a once a month injection and is known to take away the craving for heroin? ( Ideally, complemented by therapy and most likely an antidepressant)
Kathleen McDonald, RN, Vivitrol is not a good drug for people just starting their road to recovery or who don’t intend to recover. Frankly, I do not think it is a good idea period but that is my opinion. Since it blocks out the drug, people take more and more trying to get past the blocker. As well, people just starting recovery often relapse and it can set them up for an overdose. For beginning care, it is a very dangerous drug. Also, it does not address the immediate symptoms that keep people going back to their drug of choice. It does not stop the withdrawal symptoms and until the withdrawal symptoms, including post acute withdrawals, are gone, the patient is at risk of using their drug of choice and overdosing.
Sure, it may work for a few people but, overall, it is not a good choice. Someone long into their recovery and receiving therapy may benefit but it still puts them in danger.
Actually, Justme, my question specifically was to Dr. Felegi…unless you are a doctor? As a parent of a child who passed from an heroin overdose, I’ve read countless readings from kids who have successfully taken Vivitrol..and it has literally saved they’re lives. Clearly, one has to be tired if this lifestyle (and disease) and motivated to find a pathway to assist. It is clearly a multi disciplinary effort. I only wish my son had known about this before heroin took his life at 25. He was loved by so many, he just couldn’t love himself enough. In closing, the only person I’ve come across who had your opinion was a pathetic self proclaimed pastor who was a supposed recovering addict himself who thrived on the vulnerability of others.
How about this? Make it MANDATORY, not optional. If not mandatory, then at least make it so that you only get one shot at overdose reversal.
What’s the point of reviving an overdose victim if, chances are, you’ll end up reviving the victim again a few hours later? This is a budget-killer in many cities and towns, not to mention a morale-killer amongst the public safety community.
You obviously haven’t dealt with any form of addiction first hand. (And if so, even worse; judging by both your blatant ignorance and empathetic incompetence..)
It’s always seems to be the ones who know the least, who insist on spreading their lack of knowledge to the masses.
First John the cardiac diseases in the country is worse but for a different age group Are you saying if a person had more than one heart attack the ED doesn’t have to do CPR or do any life saving measures Do you know how many healthcare dollars go to Diabetes or Cardiovascular disease They are the heaviest consumers
But let’s concentrate of helping people attain wellness
Addiction is a mental and physical and illness society really doesn’t understand yet and I applaud NJ my own state for getting out there and trying but a protocol has to be in
Place to continue medication and therapy We need a lot more resources and Nurse Practitioners are becoming more available as the state grants prescribing rights for bupenorphine We are all aware more needs to be done