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.”