Drug overdose has become one of the leading causes of injury death in the United States, and much of the acute response to that crisis passes through the ED.
Each year on August 31, International Overdose Awareness Day is observed to recognize the individuals lost to drug overdose and to acknowledge the families and communities who continue to carry the weight of the ongoing crisis. For emergency departments, the day is also a moment to take stock. Drug overdose has become one of the leading causes of injury death in the United States, and much of the acute response to that crisis passes through the ED.
For many patients with opioid use disorder, the emergency department is not a peripheral point of contact. It is often the primary, and sometimes the only, medical setting in which the disease is meaningfully engaged. The ED sees patients at the moments when their disease is most acute: after an overdose reversal in the field, during withdrawal, at the point of a related infection or injury. Historically, these visits ended with a referral and a discharge summary. That approach is no longer the standard of care.
This article reviews the current role of the emergency department in the care of patients with opioid use disorder. It covers naloxone distribution at discharge, ED-initiated buprenorphine, the warm handoff to outpatient treatment, and the added complexity introduced by the fentanyl and xylazine era. On the last day of August, when much of the country is thinking about the human cost of the overdose crisis, the ED remains one of the most consequential access points in the continuum of care.
The Emergency Department as an Access Point for OUD Treatment
The role of the emergency department in the care of opioid use disorder has changed substantially in the last decade. Where the ED once functioned primarily as a place to stabilize acute overdose and manage withdrawal symptoms, current practice increasingly treats the ED as a point of initiation for evidence-based treatment. That shift reflects both a growing body of evidence and a broader recognition that traditional referral pathways were not reaching most patients.
Data from the Centers for Disease Control and Prevention show that drug overdose has been among the leading causes of injury death in the United States for more than a decade, with opioids, and increasingly synthetic opioids like illicitly manufactured fentanyl, driving the majority of deaths. Emergency departments see the acute end of that picture every shift: overdose reversals, complications of injection use, withdrawal in patients waiting for other care, and the medical sequelae of long-term opioid exposure.
The clinical implication is straightforward. Emergency clinicians are, by default, front-line providers of care for opioid use disorder. Whether a given department is prepared for that role varies, but the encounter itself is not optional. Patients present regardless of the systems in place to receive them.
Naloxone Distribution at Discharge
Naloxone remains the single most effective intervention for reversing opioid overdose in the community. For the emergency department, the practical question is not whether naloxone works but whether patients and their families are leaving the department with it in hand.
Take-home naloxone distribution has become a standard component of overdose care in many EDs and is supported by both national guidelines and a substantial body of evidence. The clinical case is direct. Patients who have overdosed once are at elevated risk of overdosing again, particularly in the first weeks after an event. Making sure that a caregiver, family member, or the patient themselves has access to naloxone at the moment they leave the department can be the difference between survival and death in a subsequent event.
In 2023, the FDA approved the first over-the-counter naloxone nasal spray, removing the prescription requirement that had complicated distribution for years. That change simplifies both the pharmacy pickup process and public access more broadly, but does not reduce the value of the ED providing naloxone directly at discharge. In many cases, the moment of discharge is also the moment of maximum receptivity, when patients or family members are actively engaged with the reality of what has happened.
Effective ED naloxone distribution programs share several features. They provide naloxone at the bedside rather than through a prescription. They include brief training for the patient and any family member or bystander who will carry it. They document the intervention in a way that is visible on future encounters. And they are paired with connections to treatment, which is where the next layer of care begins.
ED-Initiated Buprenorphine
The evidence base for ED-initiated buprenorphine has matured considerably since the landmark trial by D’Onofrio and colleagues, published in JAMA in 2015, demonstrated that patients randomized to receive buprenorphine and a referral in the ED were significantly more likely to be engaged in addiction treatment at 30 days than those who received a brief intervention or referral alone. That trial reshaped the conversation about what the ED could do and continues to anchor current practice.
ACEP’s clinical guidance on buprenorphine use in the emergency department supports ED initiation as a standard of care for patients with moderate to severe opioid use disorder who are willing to consider treatment. SAMHSA’s Medications for Opioid Use Disorder Treatment Improvement Protocol provides the broader clinical framework, including dosing guidance, considerations for polysubstance use, and populations that require additional care.
The Mainstreaming Addiction Treatment Act, enacted in late 2022, eliminated the previous federal X-waiver requirement for prescribing buprenorphine. In practical terms, this means that any DEA-registered practitioner with Schedule III prescribing authority can now prescribe buprenorphine, removing a training and administrative barrier that had limited access for years. For emergency medicine, this change lowered the operational threshold to initiation substantially.
Several practical considerations shape ED induction. Traditional protocols call for the patient to be in moderate to severe withdrawal before the first dose, typically confirmed with a Clinical Opiate Withdrawal Scale (COWS) score at a defined threshold. In the era of fentanyl-contaminated supply, however, precipitated withdrawal after even standard induction doses has become a recognized concern, and clinical protocols have evolved to address it. High-dose induction protocols and low-dose induction (microdosing) approaches are both areas of active clinical study and adoption, and the specific protocol used will depend on institutional practice and patient factors.
The CA Bridge model, developed and refined in California over the past several years, has been widely adopted as a practical operational framework for delivering ED-initiated buprenorphine, including protocols for induction, discharge with a prescription, and warm handoff to outpatient care. Its central premise is that the goal of the ED encounter is not to complete treatment but to open a door that remains open after discharge.
The Fentanyl and Xylazine Era
The clinical picture of opioid overdose has changed materially with the shift in the illicit opioid supply. Illicitly manufactured fentanyl, and increasingly its analogs, dominate the market and have complicated both reversal and treatment initiation. Prolonged sedation after reversal, atypical presentations, and precipitated withdrawal on standard buprenorphine induction protocols are all more common than they were a decade ago.
More recently, xylazine, an alpha-2 agonist veterinary sedative sometimes referred to as tranq, has emerged as a common adulterant in the illicit opioid supply, particularly in parts of the Northeast and Mid-Atlantic. The FDA has warned about the risks of xylazine exposure in humans, and clinical case series have described distinct wound patterns, prolonged and complicated withdrawal, and reduced responsiveness to naloxone, which does not reverse xylazine’s sedative effects.
For the ED, this evolving landscape has several implications. Higher cumulative naloxone doses may be needed to achieve airway protection and adequate ventilation in some overdoses, though data on optimal dosing in the fentanyl era continue to evolve. Wound care in patients exposed to xylazine requires particular attention, as the necrotic ulcerations described in the literature can be extensive and progressive. And treatment initiation protocols must account for the reality that fentanyl’s pharmacology differs meaningfully from that of heroin or prescription opioids on which older induction protocols were based.
Clinicians should not let complexity become inaction. The tools that work remain naloxone, buprenorphine, methadone in appropriate settings, and referral. The specifics of how these tools are applied are shifting, but the underlying framework holds.
The Warm Handoff to Outpatient Treatment
An ED visit for opioid use disorder that ends with a discharge instruction to call a treatment center in the morning is a visit that has, in most cases, ended prematurely. The window between the ED encounter and the next available appointment is where patients are most likely to disengage, and reducing that window is one of the highest-yield operational investments an ED can make.
Warm handoff models take several forms. In some systems, a peer recovery specialist meets the patient in the ED and accompanies them through the transition to outpatient care. In others, a same-day or next-day appointment is booked directly from the department. Some EDs maintain relationships with specific outpatient treatment programs that accept walk-in referrals during defined hours.
The evidence for peer recovery support integrated into emergency department care suggests that patients connected with a peer at the point of the visit are more likely to engage in follow-up treatment. The specific model that works best will depend on the community, the available outpatient infrastructure, and the volume of patients the department sees. What is common to effective programs is that the responsibility for connecting the patient to care sits with the department rather than being deferred to the patient at the moment of highest vulnerability.
Documentation matters. A well-documented ED encounter that names the diagnosis, records the interventions offered, and identifies the outpatient linkage protects patients from being seen as system failures in future encounters and helps subsequent clinicians pick up where the ED left off.
Building a More Coherent Response
International Overdose Awareness Day is not primarily a clinical observance. It is a public one, oriented around grief, remembrance, and advocacy. For emergency clinicians, the day is nonetheless a fitting occasion to examine the systems and habits that shape how patients with opioid use disorder are received in the department.
The elements of a strong ED response to opioid use disorder are increasingly well defined. Distribute naloxone at discharge to any patient at risk. Initiate buprenorphine in the department when clinically appropriate, using a protocol adapted to the current supply landscape. Warm-handoff patients to outpatient care rather than leaving that connection to chance. Document the encounter as the clinical event it is. And treat opioid use disorder as a medical condition with effective treatments, not as a behavioral problem to be managed at the edges of the department’s work.
The patients who present with this diagnosis carry disproportionate mortality and disproportionate stigma. Emergency departments that treat them as they would treat any other patient with a serious medical condition are also emergency departments that save lives, one encounter at a time. On the last day of August, and every day after it, that is the most meaningful acknowledgment of the loss that Overdose Awareness Day marks.
References
American College of Emergency Physicians. (2021). Buprenorphine use in the emergency department [Policy statement]. Retrieved June 2026, from https://www.acep.org/patient-care/policy-statements/buprenorphine-use-in-the-emergency-department
CA Bridge. (n.d.). Treating substance use disorders in the emergency department. Public Health Institute. Retrieved June 2026, from https://cabridge.org/
Centers for Disease Control and Prevention. (n.d.). Drug overdose deaths: Facts and figures. National Center for Injury Prevention and Control. Retrieved June 2026, from https://www.cdc.gov/overdose-prevention/data-research/facts-stats/index.html
D’Onofrio, G., O’Connor, P. G., Pantalon, M. V., Chawarski, M. C., Busch, S. H., Owens, P. H., Bernstein, S. L., & Fiellin, D. A. (2015). Emergency department-initiated buprenorphine/naloxone treatment for opioid dependence: A randomized clinical trial. JAMA, 313(16), 1636-1644. https://doi.org/10.1001/jama.2015.3474
McGuire, A. B., Powell, K. G., Treitler, P. C., Wagner, K. D., Smith, K. P., Cooperman, N., Robinson, L., Carter, J., Ray, B., & Watson, D. P. (2020). Emergency department-based peer support for opioid use disorder: Emergent functions and forms. Journal of Substance Abuse Treatment, 108, 82-87. https://doi.org/10.1016/j.jsat.2019.06.013
Substance Abuse and Mental Health Services Administration. (2021). Medications for opioid use disorder: Treatment improvement protocol (TIP) 63 (HHS Publication No. PEP21-02-01-002). Retrieved June 2026, from https://library.samhsa.gov/product/tip-63-medications-opioid-use-disorder/pep21-02-01-002
Substance Abuse and Mental Health Services Administration. (n.d.). Removal of DATA waiver (X-waiver) requirement. Retrieved June 2026, from https://www.samhsa.gov/medications-substance-use-disorders/removal-data-waiver-requirement
U.S. Food and Drug Administration. (2023). FDA approves first over-the-counter naloxone nasal spray [Press release]. Retrieved June 2026, from https://www.fda.gov/news-events/press-announcements/fda-approves-first-over-counter-naloxone-nasal-spray
U.S. Food and Drug Administration. (n.d.). FDA warns about the risk of xylazine exposure in humans. Retrieved June 2026, from https://www.fda.gov/animal-veterinary/product-safety-information/fda-warns-about-risk-xylazine-exposure-humans