ED BRIDGE is a California statewide initiative to treat patients with opioid use disorder (OUD) by induction with buprenorphine (BUP), and bridging them to outpatient MAT (medication assisted therapy) clinics.

Arrowhead Regional Medical Center is proud to be part of the California Bridge to Treatment program. In the state of  California over 200,000 patients do not have access to medical treatment for their opioid addiction. While statistics show the amount of opioid prescriptions going down, overdoses are on the rise. ARMC is committed to changing the stigma behind this disease and the medical treatment given.

ARMC will have 24-7 access to buprenorphine treatment for ALL patients regardless of income, insurance, race, creed, living situation or sexual preference.

For questions or assistance, please contact our Substance Use Navigator (SUN) Eric Alvarez.

• Phone: (909) 580-1705

• alvareze@armc.sbcounty.gov 

After hours: please leave a message or email with your name and phone number and we will call you back the next business day.

Any provider who has a DEA certification.

Click for ED BRIDGE Flow Sheet

Quick Algorithm

• Is the patient in moderate to severe opioid withdrawal? 

  • • Use clinical judgment. If uncertain, use COWS. Score ≥  8, or ≥  6 with one objective sign highly suggestive.

    • If yes, proceed. Otherwise, treat patient accordingly.

• Address any complicating factors (see detailed information below).

  • • No labs are required to induce patients with BUP.

    • Pregnancy is not a contraindication. However, patients should get prompt referral to high risk OB clinic.

    • Pregnant patients ≥  20 weeks should be referred to L&D for induction.

• Administer buprenorphine 4-8mg SL. High dose buprenorphine treatment has been shown to be safe and effective.

• Place SUN consult in EHR.

  • • If possible, confirm patient's contact info and include in consult comments.

    • The SUN will follow up with patient and arrange for most optimal outpatient referral.

    • Patient does not need to wait for consult before discharge.

• Reassess after 30-60 minutes.

  • • If symptoms improved, consider repeating dose 4-8mg SL, max 24mg SL for ED visit. Multiple doses may be given as appropriate.

    • If symptoms NOT improved, reassess patient for other diagnoses and treat accordingly.

• Upon discharge, give patient and family member the free naloxone or prescribe naloxone.

Click for ED BRIDGE Flow Sheet

Inclusion criteria:

• awake with signs of opiate W/D

• agreeable to BUP treatment

• no exclusion criteria

Exclusion criteria:

• co-ingestion of other sedative/intoxicant suspected

• AMS or unable to comprehend risks/benefits

• severe medical illness known or suspected

• reported methadone use

• non candidate for BUP maintenance

Algorithm

• BUP 16 mg SL single dose or divided doses over 1-2 hrs

• may repeat up to 32 mg total

• observe until no signs of excessive sedation or withdrawal

• Abrupt onset of opioid W/D symptoms after administration of antagonist (naloxone) or a mixed agonist/antagonist (buprenorphine)

  • • Incidence, time course, and severity vary substantially

• Precipitated W/D from low doses of buprenorphine (BUP) has been successfully treated with additional BUP

  • • Safety - BUP has ceiling for its effects on sedation and respiration

    • Benefit - ceiling for analgesic effects not been observed; ceiling for BUP treatment of precipitated W/D has not been established

• Recommended treatment algorithm:

  • • BUP 16 mg SL & lorazepam 2 mg PO once precipitated W/D is recognized

    • may repeat with BUP 16 mg SL if needed; recommend patient be on cardiorespiratory monitor

    • consider antipsychotic if agitation is primary symptom

    • if still symptomatic, continue treatment per provider's best judgement

• Ketamine for severe precipitated W/D

  • • ketamine 0.3 mg/kg IV/IM, max 30 mg/dose

    • ketamine drip may be considered

Click for ED BRIDGE Flow Sheet

• Adjunctive treatments - eg. anxiety, muscle spasms, nausea

• Non-opioid analgesia, unless contra-indicated

  • • acetaminophen

    • NSAID

• Regional anesthesia

  • • peripheral nerve blocks

    • epidural anesthesia

• Gabapentinoids

  • • reduces opioid consumption in opioid dependent patients

    • 300-600 mg PO TID

• Alpha-2 agonists

  • • anxiolytic & analgesic with opioid sparing effect

    • Clonidine 0.1-0.3 mg PO q6-8h prn

• Ketamine

  • • 0.3 mg/kg IV over 15 min infusion

    • 0.3-1 mg/kg/hr

• Magnesium

  • • NMDA antagonist with opioid sparing effect

    • 30-50 mg/kg bolus, followed by 10 mg/kg/h

• Lidocaine IV

  • • 1-1.5 mg/kg IV bolus, followed by 1.5-3 mg/kg/h

    • Must monitor serum levels after 24h

• High affinity full opioid agonist

  • • Fentanyl

    • Hydromorphone

• Additional BUP

  • • Additional or increased BUP q2h prn

    • BUP 0.3 mg IV

    • No clinical ceiling for analgesia

    • Monitor for resp depression

Treat acute withdrawal completely

• Phenobarbital is preferred

• Dose empirically based on severity 

• Generally do not switch to benzodiazepines 

• For severe cases, consider adjuncts such as dexmedetomidine, valproate, and ketamine

• For mild cases, consider oral phenobarbital

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Prescribe medication for protracted withdrawal

• Gabapentin 600 mg TID if severe; may start at 1200 mg TID

• Contraindications: renal insufficiency (eGFR<60)

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Prescribe medication to reduce craving and relapse

• Naltrexone 25-50 mg  PO daily 

• Contraindications: 

  • • Any opioid use (pills, heroin, methadone, buprenorphine)

    • Acute liver injury with AST or ALT > 250

    • Alternative: acamprosate 333mg TID PO

• Vivitrol IM extended release, currently non formulary

  • • Stay up and lateral (away from sitting pressure points), get into the butt muscle

    • It hardens fast; be ready to inject when you mix

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Place SUN consult