Prehospital Opioid Treatment Programs Show High Consistency in North Carolina

Moving Addiction Treatment Beyond the Emergency Department

Opioid use disorder and associated overdose fatalities continue to drive a major public health crisis across North America [1, 2]. While initiating evidence-based treatments like buprenorphine in the emergency department reduces morbidity and mortality, universal uptake remains inconsistent, and many patients fall through the cracks before ever reaching the hospital doors [1]. To close this gap and optimize pharmacotherapy for substance use disorders, addiction medicine specialists and emergency responders have increasingly looked toward out-of-hospital interventions, identifying prehospital buprenorphine initiation by emergency medical services as a critical frontier [1, 3]. However, data describing how these statewide prehospital programs are actually implemented and standardized in the field remain scarce. A newly published cross-sectional study of 21 counties in North Carolina maps the operational landscape of these early-intervention models, revealing that 19 of the active programs successfully offered bridge dosing and 43% utilized a 16-milligram induction dose for patients experiencing opiate withdrawal [4].

Mapping the Prehospital Landscape

Prehospital programs for medications for opioid use disorder (MOUD) have gained significant traction over the past few years as a strategy to reach patients who might otherwise avoid traditional healthcare settings. Despite this growth, data describing the statewide implementation of MOUD programs are limited, leaving clinicians and emergency medical services directors without a clear blueprint for operational success. To address this knowledge gap, researchers designed a cross-sectional study evaluating 21 counties in North Carolina that maintained an active prehospital MOUD program at the time of the analysis. The primary objective of the study was to describe current practices within these active programs, detailing how emergency responders initiate addiction pharmacotherapy in the field.

To capture a comprehensive picture of these interventions, the investigators conducted virtual and phone interviews with program leaders across the state. During these sessions, the counties answered predefined qualitative and quantitative questions related to their specific program structure and operational elements. The researchers then analyzed the interview data using descriptive statistics. To assist in standardizing future programs, the study compared the North Carolina prehospital MOUD data with previously published best practices. Specifically, the findings were combined into a comparative format based on current best practice consensus recommendations. For practicing physicians, this comparison is highly relevant: understanding how closely real-world emergency medical services protocols align with established clinical guidelines helps emergency department and outpatient clinicians anticipate the exact pharmacological baseline of patients arriving from the field.

Program Structure and Personnel

The researchers evaluated the operational frameworks of these emergency interventions, identifying that a total of 21 counties in North Carolina had an active prehospital MOUD program. For the purposes of the study, an active program was defined as having administered at least one induction dose of medication to a patient in the field. When examining the clinical protocols guiding these interventions, the investigators found a high level of standardization regarding patient selection. Specifically, patient inclusion criteria were identical across all 21 active MOUD programs. This uniformity suggests that emergency medical services systems across the state have adopted a cohesive clinical threshold for identifying patients who are appropriate candidates for out-of-hospital buprenorphine initiation, ensuring that downstream receiving physicians see a consistent patient profile.

While patient selection protocols were uniform, the study noted slight variations in the staffing models used to deliver the medication. The administration of buprenorphine in the prehospital setting requires specific clinical training, and most systems restricted this responsibility to advanced providers. In 20 counties (95%), only community paramedics or other specialized personnel like emergency medical services supervisors were authorized to administer MOUD. Community paramedics typically undergo additional training beyond standard certification to manage chronic diseases and navigate complex behavioral health needs. Conversely, a more decentralized approach was observed in a small minority of the surveyed regions. In one county (5%), any paramedic in the system was allowed to administer MOUD, highlighting an alternative model that maximizes the number of potential responders equipped to initiate addiction pharmacotherapy during routine emergency calls.

Dosing Protocols and Bridge Therapy

Beyond the initial induction of buprenorphine, prehospital programs must ensure patients do not experience a lapse in medication before they can establish ongoing care at an outpatient clinic. To address this vulnerable transition period, the researchers evaluated the prevalence of bridge dosing (a practice that involves supplying patients with additional medication to manage their symptoms until a formal follow-up appointment occurs). The study found that out of the 21 active programs, 19 offered bridge dosing as part of their standard protocol. Furthermore, these protocols were actively utilized in the field, as 18 programs (86%) had administered at least one bridge dose to a patient. For outpatient addiction specialists, this high rate of implementation indicates that emergency medical services are not only initiating treatment but also actively bridging the gap to long-term care, reducing the likelihood of immediate relapse.

The investigators also examined the specific pharmacological protocols used for initial buprenorphine induction, comparing local practices against established clinical guidelines. Guidelines often recommend a higher initial dose to rapidly achieve receptor blockade and provide adequate symptom relief in the field. Regarding induction therapy and the consensus recommendation of a 16-milligram dose, the researchers noted that nine counties (43%) utilized this dose for patients experiencing opiate withdrawal. The dosing strategies shifted when treating patients who had just been resuscitated from an acute emergency. Specifically, 13 counties (62%) used the 16-milligram dose for patients experiencing withdrawal post-overdose reversal with naloxone. These findings highlight that while a majority of agencies align with the 16-milligram consensus recommendation for post-resuscitation care, there remains regional variation in how emergency responders dose buprenorphine based on the specific clinical trigger for the withdrawal symptoms.

A Replicable Model for Standardized Care

Overall, the analysis revealed that prehospital programs delivering medications for opioid use disorder in North Carolina demonstrated broad consistency, with only small variations in dosing, funding sources, hours of available treatment, and team composition. By mapping these operational details across the state, the study demonstrated significant consistency in the approaches of North Carolina emergency medical services systems in the care of opioid use disorder. This uniformity suggests that despite the decentralized nature of emergency response agencies, regional systems can successfully align their clinical protocols to deliver standardized addiction treatment in the field.

For clinicians and public health officials looking to expand access to addiction pharmacotherapy, the North Carolina approaches provide replicable models that other states can use to drive forward prehospital programs and create a national standard of care. Establishing such a standard is critical for ensuring that patients receive evidence-based interventions regardless of their geographic location, ultimately streamlining the handoff between emergency responders and receiving physicians. However, operational success is only the first step in mitigating the overdose crisis. Moving forward, further studies are needed to link prehospital efforts to associated patient-centered outcomes, such as long-term retention in outpatient treatment, reductions in subsequent overdoses, and overall mortality rates.

References

1. Cowan E, Perrone J, Bernstein SL, et al. National Institute on Drug Abuse Clinical Trials Network Meeting Report: Advancing Emergency Department Initiation of Buprenorphine for Opioid Use Disorder. Annals of Emergency Medicine. 2023. doi:10.1016/j.annemergmed.2023.03.025

2. Martín F, Gosse M, Whelan E. ‘Planning for a healthy baby and a healthy pregnancy’: A critical analysis of Canadian clinical practice guidelines for the treatment of opioid dependence during pregnancy. Sociology of Health & Illness. 2023. doi:10.1111/1467-9566.13721

3. Hiemke C, Bergemann N, Clement H, et al. Consensus Guidelines for Therapeutic Drug Monitoring in Neuropsychopharmacology: Update 2017. Pharmacopsychiatry. 2017. doi:10.1055/s-0043-116492

4. Ozelkan LA, Tayes CD, Otterson JK, Winslow JE, PJoiner A, Grover JM. An Analysis of Medications for Opioid Use Disorder (MOUD) Prehospital Programs Across North Carolina.. Prehospital emergency care. 2026. doi:10.1080/10903127.2026.2637914