DELAWARE OVERDOSE SYSTEM OF CARE GUIDANCE DOCUMENT ON OPIOID USE DISORDER IN THE EMERGENCY DEPARTMENT

EXECUTIVE SUMMARY

Delaware faces one of the highest opioid overdose rates in the nation, with over 2,000 suspected
overdoses presenting to emergency departments (EDs) each year. In response, the Delaware Overdose
System of Care (OSOC) developed this Guidance Document to establish a consistent, evidence-based
approach for identifying and treating opioid use disorder (OUD) in ED settings. The guidance reflects
collaboration among Emergency Medicine and Addiction Medicine physicians and clinicians, Emergency
Medical Services (EMS), pharmacists, behavioral health professionals, and state leaders, aligning with
national recommendations from the American College of Emergency Physicians (ACEP). The goal of this
Guidance Document is to serve as a framework for health-system policymaking and as a best-practice
reference for Emergency Departments in Delaware.

The document outlines standardized best practices, emphasizing five priority areas:

Screening: Implement brief, validated tools integrated into triage or electronic health record
(EHR) workflows, supported by staff education and stigma-reduction training.
Patient Engagement: Use trauma-informed, patient-centered communication and expand
access to Certified Peer Recovery Specialists and Care Navigators to support consistent, 24/7
engagement.
Medication Initiation & Withdrawal Care: Adopt flexible buprenorphine-naloxone initiation
protocols, including high-dose (macro-induction) and home-start options, with built-in EHR
order sets for efficiency and safety in starting medication and managing withdrawal.
Transitions of Care: Utilize the Delaware Treatment Referral Network (DTRN) for seamless
referrals and warm handoffs to community providers, supported by care navigators and telenavigation options.
Documentation and Billing: Use specific diagnosis and billing codes (e.g., G2213) to ensure
accurate tracking, reimbursement, and program sustainability.
By standardizing OUD management in EDs, these guidelines aim to improve care quality, reduce
overdose deaths, streamline ED workflows, and strengthen coordination between hospitals, community
providers, and state systems—ultimately supporting recovery and continuity of care for all Delawareans
affected by opioid use disorder.

PURPOSE AND BACKGROUND

Delaware ranks in the top three states in the country for opioid overdose deaths, and the state’s
emergency departments (EDs) encounter an average of 2,062 suspected opioid overdoses every year
since 20211
. While some national guidelines exist, ED clinicians take varied approaches to patient
1 Delaware Department of Health and Social Services, Division of Public Health, National Syndromic Surveillance PlatformElectronic Surveillance System for the Early Notification of Community-based Epidemics (NSSP-ESSENCE).
3 DE OSOC Guidance Document on Opioid Use Disorder in the Emergency Department
engagement, stabilization, treatment initiation, and continuity of care. Such variation may be due to
facility-specific resources and constraints, but the lack of consistency may also hinder quality and trust
for patients and at the systems level.

The Delaware Overdose System of Care (OSOC) was established in 2018 by Delaware Legislation and
brings together hospitals, EMS, community treatment providers, and state partners to coordinate
treatment and care provided to individuals who have overdosed or require acute management of OUD.
The work of OSOC is monitored by the Data & Quality Subcommittee using four North Star measures
that we developed in collaboration with ED clinicians and other stakeholders:

Medications for opioid use disorder (MOUD) prescription at ED discharge.
Outpatient engagement in follow-up treatment following ED discharge.
MOUD initiated after ED discharge.
Sustained engagement in MOUD treatment.
The OSOC Acute OUD Stabilization Subcommittee Co-Chairs and OSOC Medical Advisor jointly proposed
a multi-year project to develop referral pathways and a Guidance Document that represents OSOC’s
recommendations for opioid use disorder (OUD) care in the Delaware ED setting. This consensus-driven
document summarizes components of standards of care and best practices, including but not limited to:

Screening and triage
Patient engagement
Buprenorphine initiation protocols, including dosing and withdrawal management
Discharge and transitions of care
Funding, including coding and billing
The Guidance Document was informed by the OSOC Acute OUD Stabilization Subcommittee Working
Group, local and regional ED and EMS experience, and the American College of Emergency Physicians
(ACEP) consensus recommendations on the treatment of opioid use disorder in the emergency
department2
.
Unlike Stroke or Trauma Systems of Care with regulatory requirements to comply with common
standards, the OUD Guidance Document does not include a formal compliance structure. However,
establishing a standardized approach to care allows for improved consistency in care and benchmarking
across the state. Delaware health systems and EDs are encouraged to incorporate the framework and
guidelines in this document to guide policymaking and improve standardization of OUD care across
Delaware Emergency Departments.
2 Hawk K, Hoppe J, Ketcham E, et al. Consensus recommendations on the treatment of opioid use disorder in the Emergency
Department. Annals of Emergency Medicine. 2021;78(3):434-442. doi:10.1016/j.annemergmed.2021.04.023
4 DE OSOC Guidance Document on Opioid Use Disorder in the Emergency Department
TABLE OF CONTENTS
Executive Summary …………………………………………………………………………………………………………………………………….2
Purpose and Background……………………………………………………………………………………………………………………………..2
Table of Contents ……………………………………………………………………………………………………………………………………….4
Version History …………………………………………………………………………………………………………………………………………..5
Working Group Participants…………………………………………………………………………………………………………………………6
Acknowledgements…………………………………………………………………………………………………………………………………….7
Patient Screening………………………………………………………………………………………………………………………………………..7
Overview of Current State (March 2025) ………………………………………………………………………………………………..7
Delaware Recommendations…………………………………………………………………………………………………………………8
Patient Engagement ………………………………………………………………………………………………………………………………….11
Overview of Current State (January 2025) …………………………………………………………………………………………….11
Delaware Recommendations……………………………………………………………………………………………………………….12
Starting Medication for Opioid Use Disorder (MOUD) in the ED ……………………………………………………………………..13
Overview of Current State (November 2024 meeting; October 2025 update)……………………………………………13
Important Considerations……………………………………………………………………………………………………………………14
Overview of MOUD Initiation Recommendations…………………………………………………………………………………..14
Evaluate for Opioid Use Disorder (OUD) ……………………………………………………………………………………………….15
Identify and Treat Opioid Withdrawal in the ED …………………………………………………………………………………….15
Discuss Medications for Opioid Use Disorder (MOUD) ……………………………………………………………………………16
Emergency Department Buprenorphine Initiation Recommendations………………………………………………………18
Home Start………………………………………………………………………………………………………………………………………..21
Hospitalization needs …………………………………………………………………………………………………………………………21
Special Populations…………………………………………………………………………………………………………………………….21
Buprenorphine Precipitated Withdrawal ………………………………………………………………………………………………22
MOUD-Specific References:…………………………………………………………………………………………………………………23
Electronic Health Record (EHR) Integration and Sample EHR OUD Discharge SmartSet ………………………………23
Transitions of Care…………………………………………………………………………………………………………………………………….23
Overview of Current State (September 2024)………………………………………………………………………………………..23
Delaware Recommendations……………………………………………………………………………………………………………….24
Documentation and Reimbursement (Coding and Billing)………………………………………………………………………………29
5 DE OSOC Guidance Document on Opioid Use Disorder in the Emergency Department
Diagnosis…………………………………………………………………………………………………………………………………………..29
Starting MOUD in the ED…………………………………………………………………………………………………………………….30
Reducing Overdose Risk, Complications, and Harm from Opioid Use Disorder………………………………………………….30
Conclusion ……………………………………………………………………………………………………………………………………………….31
References……………………………………………………………………………………………………………………………………………….32
MOUD-Specific References………………………………………………………………………………………………………………….34
Appendix A. Buprenorphine Frequently Asked Questions and Suggested Responses…………………………………………37
Medication Education…………………………………………………………………………………………………………………………37
Precipitated Withdrawal……………………………………………………………………………………………………………………..38
Ineffective Medication………………………………………………………………………………………………………………………..38
Stigma-related …………………………………………………………………………………………………………………………………..39
Other Concerns………………………………………………………………………………………………………………………………….40
Transportation Issues …………………………………………………………………………………………………………………………41
Insurance/Payment ……………………………………………………………………………………………………………………………41
Appendix B. Adjunctive and Supportive Treatments for Withdrawal ……………………………………………………………….43
Appendix C. Considerations for Methadone in the ED……………………………………………………………………………………45
Appendix D. ED Discharge Checklist…………………………………………………………………………………………………………….46
Appendix E. Checklist to Evaluate for Opioid Use Disorder (OUD)……………………………………………………………………47
Appendix F. Clinical Opiate Withdrawal Scale (COWS)……………………………………………………………………………………48
Appendix G: Buprenorphine Home Initiation………………………………………………………………………………………………..50
Appendix H. Instructions for Starting Buprenorphine in the ED ………………………………………………………………………52
Appendix C: Definitions and Role Clarifications, Developed by DSAMH ……………………………………………………………54
VERSION HISTORY
First published Monday, November 3, 2025.
Version Release Date Summary of Changes Author
1.0 11/03/2025 Initial release. Working Group members.
1.1 01/11/2026 Updated Insurance/Payment section of
Appendix A.
Kate Brookins and Margot Swift.
6 DE OSOC Guidance Document on Opioid Use Disorder in the Emergency Department
WORKING GROUP PARTICIPANTS
OSOC CoChairs
Joanna Champney, Director, Division of Substance Abuse and Mental Health
Rebecca Walker, PhD; Deputy Director, Division of Public Health, Director Clinical &
Science Operations
Acute OUD
Stabilization
Subcommittee
Co-Chairs
Robert Rosenbaum, MD; State EMS and Preparedness Section Medical Director, Delaware
EMS Fellowship Faculty, EMS and Preparedness Section, Office of Emergency Medical
Services, Division of Public Health
Kate Brookins; Chief of Addiction and Transition Services, Division of Substance Abuse and
Mental Health
Systems of
Care
Paul Westlake; Systems of Care Coordinator, EMS and Preparedness Section, Office of
Emergency Medical Services, Division of Public Health
ChristianaCare • Gregory Wanner, DO; Director of Public Health & ED Opioid Use Disorder Treatment; EMS
Special Projects Medical Director, EMS and Preparedness Section, Office of Emergency
Medical Services, Division of Public Health
Kate Groner, MD; Vice-Chair of Emergency Medicine
Brittany Cesar, MD; EM/Addiction Medicine Attending Physician
Peter Lorenz, MD; EM/IM Resident Physician
Saira Khan, DO; Physician EMS Fellow, ChristianaCare/Office of Emergency Medical
Services
Alex Blau, DO; Physician EMS Fellow, ChristianaCare/Office of Emergency Medical Services
Mike Perza, PharmD; ED Pharmacist
Beebe • Nicholas Perchiniak, MD; Chair of Emergency Medicine
Keith Kuhfahl, DO; Associate Medical Director, Emergency Services
Jennifer Mancuso, MSN, RN; Behavioral Health Nurse Manager
St. Francis • Emily Murphy, MD; EMS Medical Director
Jaime Roques, MD; Interim ED Medical Director
Evan Lynn, MD; ED Medical Director
Bayhealth • Frank Mayer, DO; Assistant Medical Director, Smyrna and Kent Campuses; Assistant
Medical Director, Kent County EMS
Aamer Khan, MD
Julie Cullen, DO; Medical Director, South Campus
Bryan Choi, MD; Medical Director, Kent County EMS
John Fink, MD
TidalHealth
Nanticoke
Elizabeth Koval, MD; Medical Director and Chair of Emergency Services
Nicholas Colazzo, MD; Assistant Medical Director and Vice Chair of Emergency Services
7 DE OSOC Guidance Document on Opioid Use Disorder in the Emergency Department
ACKNOWLEDGEMENTS
The Working Group participants and Acute OUD Stabilization Subcommittee Co-Chairs would like to
thank our colleagues in Delaware and Philadelphia for their assistance in developing the Guidance
Document. Thanks to Charles McClure, MD, Addiction Medicine Physician and Vishesh Agarwal, MD,
Chair of Addiction Medicine at ChristianaCare for their assistance.
PATIENT SCREENING
OVERVIEW OF CURRENT STATE (MARCH 2025)
Practices to screen for and identify patients with opioid use disorder (OUD) vary across Delaware
emergency departments (EDs). Working group participants noted their EDs often rely on ad hoc or
provider-specific practices to identify patients with OUD, rather than a universal or standardized
approach. Patients are most commonly identified if they present after an overdose, in withdrawal, or
requesting medication for opioid use disorder (MOUD) or opioids, which can result in missing less overt
cases. Some hospitals apply SBIRT (universal screening, brief intervention, and referral to treatment)
selectively (e.g., for trauma patients). One participating hospital asks questions about substance use
during triage and a positive response prompts a referral to a behavioral health nurse. Overall, OUD
screening varies by institution and provider, with only a subset regularly initiating conversations about
substance use and treatment.
Working group participants queried their colleagues prior to the March 2025 working group meeting to
learn what prevents them from screening patients for OUD or initiating conversations about substance
use and several themes arose. Clinicians expressed discomfort initiating OUD discussions, and stigma
may be a barrier to consistent engagement. One individual noted it is hard to prioritize conversations
about substance use when they don’t even have enough resources to manage other acute or chronic
conditions while working in a busy ED. Additionally, several EDs represented in the working group rely
heavily on care navigators for patient engagement, and when navigators are unavailable, screening,
engagement, and referrals drop sharply.
Perhaps the largest barriers to screening patients and initiating conversations about substance use are
real or perceived gaps in resources and referral pathways. Working group participants noted that the
Delaware Treatment Referral Network (DTRN), formerly known as Open Beds referral system is used but
is sometimes slow and inefficient, causing long ED stays. Additionally, pathways for outpatient or
intermediate care can be unclear or confusing, and many ED providers are unfamiliar with community
resources. This knowledge gap and lack of a simple referral resource may be preventing staff from
sufficiently screening because they worry about not being able to offer additional support if a patient
screens positive.
8 DE OSOC Guidance Document on Opioid Use Disorder in the Emergency Department
DELAWARE RECOMMENDATIONS
Any recommendations around implementing substance use or OUD screening must balance the
competing priorities and time constraints of busy EDs. The recommendations below are intended to
mitigate the barriers to patient screening raised by working group participants. However, as described
above, a major reason why ED staff don’t screen for substance use or OUD is lack of streamlined, easy to
access resources and referral pathways to connect patients to ongoing community care. The
recommendation for the State and health system leadership to support simple, streamlined
engagement and referral protocols is discussed further in the next section, Patient Engagement.
STAFF TRAINING AND STIGMA REDUCTION
Working group participants’ conversations with their colleagues illuminated that some stigma around
substance use and OUD remains and may prevent staff from prioritizing OUD screening. Although there
has been significant progress in decreasing stigma among healthcare providers, there remains
opportunity for growth. Delaware emergency departments are encouraged to implement staff training
and stigma reduction in accordance with the following guidelines:
Establish a culture where SUD and OUD are viewed and approached the same as any other
chronic disease.
Regularly make training available to all ED staff – nurses, physicians, and social workers – on
MOUD, trauma-informed care, and stigma reduction.
Use simulations, case studies, and peer mentoring to build provider confidence and normalize
OUD care.
The State and health system leadership can support implementing standardized screening protocols in
the following ways:
Launch a statewide educational campaign to reduce stigma and promote OUD treatment as part
of standard emergency care.
Leverage the OSOC Acute OUD Stabilization Subcommittee to facilitate a statewide collaborative
for peer learning, feedback, and shared problem-solving across EDs on topics related to SUD and
OUD.
STANDARDIZED SCREENING PROTOCOLS
Working group participants noted that substance use and OUD screenings are typically ad hoc and
provider dependent. Standardizing screening protocols for all patients can take the onus off staff to
determine if or when to screen a patient and increase the likelihood of identifying patients in need of
substance use or OUD support. Delaware emergency departments are encouraged to implement
standardized screening protocols in accordance with the following guidelines:
9 DE OSOC Guidance Document on Opioid Use Disorder in the Emergency Department
Implement uniform screening protocols for substance use and OUD, potentially integrated into
triage or social history workflows. Several validated screening tools are available, each with their
own strengths and weaknesses. The goal is a quick screening tool to help identify at-risk
individuals, with the understanding of time constraints in a busy ED. The working group does not
endorse one specific screening tool. Rather, we encourage EDs to implement a screening tool
that best fits within the workflow of each ED and hospital system.
o Examples of standardized drug and alcohol use screening tools:
▪ CAGE Adapted to Include Drugs (CAGE-AID)
Four questions
Clinician or self-administered
▪ Tobacco, Alcohol, Prescription Medication, and Other Substance Use (TAPS)
Four questions (TAPS-1), additional questions depending on responses
Clinician or self-administered
▪ Two-Item Conjoint Screen (TICS)
Two questions
Developed for primary care
▪ Screening to Brief Intervention (S2BI)
Three to seven questions, depending on responses
Clinician or self-administered
Adolescent-specific
▪ Brief Screener for Tobacco, Alcohol, and Other Drugs (BSTAD)
Three to five questions, depending on responses
Clinician or self-administered
Adolescent-specific
Develop processes for brief intervention and referral in patients who screen positive.
The State and health system leadership can support implementing standardized screening protocols in
the following ways:
Develop and disseminate statewide evidence-based clinical protocols for substance use and
OUD screening and brief interventions, including decision aids and scripts.
Provide technical and financial resources for integration of screening tools into EHR systems.
Leverage OSOC resources (including the Data & Quality Subcommittee) to evaluate adherence
to protocols and track key metrics (e.g., buprenorphine initiation rates, referral completions,
follow-up engagement).
Positive screen should prompt an action leading to further assessment, diagnosis or treatment.
Resources and Structures to Support SUD Screening
Universal Triage Screening and EHR Nudge – Penn’s Perelman School of Medicine
10 DE OSOC Guidance Document on Opioid Use Disorder in the Emergency Department
Implemented 1) triage screening question asked by nurses and 2) automated nudge in EHR to
make clinicians aware of patients with OUD.
Number of OUD assessments doubled and MOUD initiation increased.
Lowenstein M, McFadden R, Abdel-Rahman D, et al. Redesign of Opioid Use Disorder Screening
and Treatment in the ED. NEJM Catal Innov Care Deliv. 2022;3(1):10.1056/CAT.21.0297.
doi:10.1056/CAT.21.0297. Accessed at:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10641724/
Lowenstein M, Perrone J, McFadden R, et al. Impact of universal screening and automated
clinical decision support for the treatment of opioid use disorder in emergency departments: A
Difference-in-Differences analysis. Annals of Emergency Medicine. 2023;82(2):131-144.
doi:10.1016/j.annemergmed.2023.03.033. Accessed at:
https://www.annemergmed.com/article/S0196-0644(23)00265-2/fulltext
Train All Staff and Standardize Protocols – Cooper University Health Care ED
Trained all ED physicians and residents in MOUD (buprenorphine and methadone, naltrexone
for AUD) and supporting topics (e.g., stigma and language).
Created protocols for opioid withdrawal assessment, buprenorphine initiation, methadone
initiation, naltrexone for AUD, and linkage to community treatment.
#NDAFW: Emergency Medicine and Hospital-Based Addiction care available at Cooper. eHealth
Connection. Published March 27, 2023. Accessed October 13, 2025.
https://blogs.cooperhealth.org/ehealth/2023/03/27/ndafw-emergency-medicine-and-hospitalbased-addiction-care-available-at-cooper/
#NDAFW: medications for substance use disorders, increasing access to treatment, and
decreasing stigma. eHealth Connection. Published March 22, 2023. Accessed October 13, 2025.
https://blogs.cooperhealth.org/ehealth/2023/03/22/ndafw-medications-for-substance-usedisorders-increasing-access-to-treatment-and-decreasing-stigma/
Screen Broadly and Post Signs to Encourage Patients to Seek Care – CA Bridge
Ask about OUD in patients with:
o Opioid withdrawal symptoms
o Sequelae of injection use
o Skin and soft-tissue infections
o Endocarditis
o Flu-like symptoms
o Nausea, vomiting, and/or diarrhea
o Acute or chronic hepatitis C or HIV positivity
o Positive urine toxicology testing
o Use of al

Empower patients to share SUD by posting signs letting them know support is available

Blueprint for Hospital Opioid Use Disorder Treatment. California Department of Health Care
Services; 2022. Accessed October 13, 2025. https://bridgetotreatment.org/resource/blueprintfor-hospital-opioid-use-disorder-treatment/

PATIENT ENGAGEMENT
OVERVIEW OF CURRENT STATE (JANUARY 2025)
Strategies for engaging patients with opioid use disorder in Delaware emergency departments vary
considerably by provider and by institution. No healthcare system has a standardized protocol for
initiating conversations around opioid or substance use, but all participants described their own
approaches for beginning the conversation. Strategies shared by working group members include the
following:
Understanding why a patient is in withdrawal in the ED. Sometimes patients come specifically
because they want to stop using and want help, and these patients are usually the most open to
engaging in a conversation about starting buprenorphine/MOUD.
Validating patients’ discomfort and talking about the best options to make them feel better. This
builds rapport and reassures them the ED staff are taking them seriously.
Talking about withdrawal and understanding the patient’s situation and possible reasons for
using, which can help calm them down and open the door for a conversation about starting
MOUD.
Asking about past experiences with withdrawal and with trying MOUD.
Working group participants also described several barriers to improving patient engagement around
MOUD. A major limitation that prevents ED staff from engaging patients in discussions about MOUD is
the lack of a simple, streamlined referral process to transition patients from the ED to ongoing
community treatment.
Another barrier is clinician discomfort around initiating conversations about OUD, especially when
patients are in acute crisis or are ambivalent about beginning MOUD. ED clinicians are typically not
experts on MOUD and may have discomfort answering patients’ questions about withdrawal, various
medications and their side effects, and long-term treatment options. Relatedly, there remains stigma
towards patients with OUD that may be hindering these conversations.
Working group participants also noted it can be difficult to convince their ED physicians to think about
OUD like any other medical problem. This challenge seems partly due to an education gap, more so for
more senior clinicians. These individuals often did not receive education on OUD or MOUD until recently
and even then, often must choose to seek it out. Additionally, ED staff have many competing priorities,
12 DE OSOC Guidance Document on Opioid Use Disorder in the Emergency Department
and engaging patients in conversations about MOUD is sometimes seen as optional or secondary,
depending on staffing levels and time pressures.
DELAWARE RECOMMENDATIONS
PATIENT-CENTERED AND TRAUMA-INFORMED ENGAGEMENT STRATEGIES
A recurring theme in the discussion of patient engagement was the importance of making patients feel
heard, understood, and cared for. Delaware emergency departments are encouraged to implement
strategies designed to facilitate engagement with patients with, including the following guidelines:
Check in with patients regularly throughout their time in the ED to ensure they understand next
steps and feel prioritized. Acknowledging ED clinicians have time pressures, these can be very
brief check-ins, no more than 1-2 minutes.
Take a judgement-free, destigmatizing approach to patient interactions, including using personcentered language and avoiding generalizations about people with OUD.
Believe and validate patients’ experiences, symptoms, and concerns about starting MOUD or
other OUD treatment.
Discuss the patient’s perspective on their substance use, their desire and motivations for
change, hopes/plans, and openness to treatment.

CARE NAVIGATORS, PEERS, AND BEHAVIORAL HEALTH STAFF TO SUPPORT PATIENT
ENGAGEMENT
Employing Care Navigators, peers, and increasing ED access to behavioral health support is a top priority
among Delaware ED and treatment provider leaders. A peer who has lived experience with MOUD is
able to describe the experience of using various medications, share information about recovery process,
and help the patient engage in a collaborative relationship with the treatment team. One working group
member noted that peers have been “the most impactful thing” they’ve seen in the ED when it comes to
patient engagement. Additionally, peer availability can help ED clinicians balance the time constraints
and high patient volumes in a busy ED by providing additional support to the patient. Delaware
emergency departments are encouraged to implement peer supports in accordance with the following
guidelines:
Work towards 24/7 access to peer support, either in person or by phone, to support ED
clinicians with patient engagement and trust building. Working group participants affirmed that
tele-peer support would be a helpful resource and utilized by staff.
Where peers are not available, consider on-call behavioral health specialists to help facilitate
patient engagement around MOUD and care navigators to support follow-up planning.
The State and health system leadership can support implementing the peer and behavioral health staff
guidance in the following way:
13 DE OSOC Guidance Document on Opioid Use Disorder in the Emergency Department
Streamline peer access: Consider whether existing State resources (e.g., the Bridge Clinics) can
be leveraged to provide 24/7 peer support to EDs. Establish a single phone number or other
simple, streamlined process to connect patients with a peer to facilitate engagement and
discharge planning.
SIMPLE, STREAMLINED ENGAGEMENT AND REFERRAL PROTOCOLS
Working group participants noted several interconnected barriers to engaging patients in discussions
around MOUD. ED clinicians typically are not experts in OUD or MOUD, have limited time and
competing priorities, and are often unsure about what resources exist for patients after the ED. All these
challenges point to the need for a simple, streamlined process for identifying, engaging, and referring
patients (referrals are discussed further in the Transitions of Care section). ED representatives noted a
need for a single contact point or phone number they could call to assist with identifying patients’
needs, discussing treatment options, and facilitating follow-up.
While emergency departments are encouraged to implement their own engagement protocols and
specialized training for ED clinicians, working group members specifically pointed to the need for a
single, statewide option. The State and health system leadership can collaborate to help fill this gap in
the following way:
As described above, consider whether existing State resources (e.g., the Bridge Clinics) can be
leveraged to provide 24/7 patient engagement and referral support to EDs. ED representatives
noted the need for a simple way (e.g., single phone number) to connect patients to an individual
who can provide information about treatment options and what might be the best fit, answer
their questions, and facilitate a referral and next steps.

FREQUENTLY ASKED QUESTIONS AND RECOMMENDED RESPONSES
There are common questions that often arise when discussing buprenorphine with patients and ED
clinicians may be uncomfortable beginning the conversation or answering these questions. To support
clinician preparedness, Appendix A contains frequently asked questions, background information on
some key concepts, and recommended responses to questions that have been asked by patients.
STARTING MEDICATION FOR OPIOID USE DISORDER (MOUD) IN THE ED
OVERVIEW OF CURRENT STATE (NOVEMBER 2024 MEETING; OCTOBER 2025
UPDATE)
All hospital partners have practices for starting patients on MOUD in the emergency department,
though there is some variation in specific protocols for starting buprenorphine or methadone. In
general, patient eligibility is determined using the Clinical Opiate Withdrawal Scale (COWS) and other
criteria. Eligible patients may be given buprenorphine or methadone, then reassessed. Adjunctive
14 DE OSOC Guidance Document on Opioid Use Disorder in the Emergency Department
medications are also typically used to help manage symptoms. Some hospitals offer patients the
opportunity to start buprenorphine at home and provide instructions with their discharge materials.

IMPORTANT CONSIDERATIONS
ADULTERANTS IN THE STREET OPIOID SUPPLY
Polysubstance adulterants have become an increasingly larger issue in the management of overdose and
withdrawal. Recent adulterants have included xylazine, novel benzodiazepines, and medetomidine.
While medetomidine withdrawal is addressed in the “Adjunctive and Supportive Treatments for
Withdrawal” section (Appendix B), these guidelines cannot cover all possible adulterants. It is important
to recognize the ever-changing landscape of contents in the street drug supply. These changes can cause
difficulties in policymaking for health systems. While high-quality research-based evidence is ideal, as
novel adulterants rapidly emerge oftentimes the only available evidence for treatments are experiencebased expert opinion, case studies, and small retrospective reviews. An understanding of these unique
challenges is important. We encourage flexibility in health system policymaking with consideration of
benefit versus risk based on available evidence and understanding that highest-quality evidence may be
limited. We also recommend monitoring local trends and subscribing to Delaware’s Overdose Response
Center (ORC) Street Drug Report (email ORC@delaware.gov and ask to be added to the email list) and
Health Alert Network (HAN) messages for Delaware, surrounding states, and CDC.

WITHDRAWAL MANAGEMENT (“DETOX”) REFERRALS
For patients requesting assistance with entering a withdrawal management (“detox”) facility,
requests/referrals must be appropriate to the patient-specific factors. For example, a patient with active
behavioral/mental health difficulties along with OUD may be appropriate for an “institution for mental
diseases” (IMD) facility, however, withdrawal management/detoxification alone would be appropriate
for a withdrawal management/detox facility, rather than an IMD. In unclear cases, discussion with an
addiction medicine and/or psychiatry/mental health professional can assist with directing post-ED or
post-hospital level of care recommendations. Patients should be encouraged to start MOUD at the
withdrawal management facility and continue MOUD after discharge from the facility, as the risk of
returning to opioid use is very high when not on MOUD. Additionally, with loss of opioid tolerance, there
is a very high risk of overdose after “detox” and return to use. This should be considered when
discussing withdrawal management (“detox”) with patients.

OVERVIEW OF MOUD INITIATION RECOMMENDATIONS
The recommendations below were developed with safety in mind and are intended to be flexible and
can be tailored to each individual ED’s needs. Health systems are encouraged to implement a formalized
program for starting MOUD. The following guidelines may be used to build a standardized program in
each facility. The working group recommends the following approach:
15 DE OSOC Guidance Document on Opioid Use Disorder in the Emergency Department

Evaluate the patient for opioid use disorder (OUD) diagnosis.
Assess the patient’s Clinical Opiate Withdrawal Scale (COWS) score.
Provide opioid withdrawal treatments, including adjunctive and supportive medications.
Discuss MOUD.
Consider starting MOUD:
a. Buprenorphine/naloxone (Suboxone) in the ED (if meeting criteria) or at home, OR
b. Methadone in the ED (Appendix C).
Assist with follow-up planning; involve a Care Navigator, Social Worker, or Case Management (if
available).
Provide prescriptions for Suboxone (if applicable), symptom-control medications, and a
naloxone rescue kit (preferred) or prescription for naloxone, and adjunctive/symptomatic
medications. Naloxone “Opioid Rescue Kits” are available free of charge from DSAMH.
(Discharge checklist available in Appendix D).
Integrate this process into the electronic health record (EHR) system, if possible.
Details for these recommendations are below.
EVALUATE FOR OPIOID USE DISORDER (OUD)
While an OUD diagnosis is often clear based on a brief conversation with the patient and review of
records, the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) includes
specific criteria for OUD diagnosis. See Appendix E for an OUD diagnosis checklist.
IDENTIFY AND TREAT OPIOID WITHDRAWAL IN THE ED
Assess withdrawal using the Clinical Opiate Withdrawal Scale (COWS) (Appendix F). Consider the
following recommendations for opioid withdrawal treatment in the ED:
ALL ED PATIENTS WITH OPIOID WITHDRAWAL:

Symptomatic treatments are first-line for opioid withdrawal in the ED (See “Adjunctive and
Supportive Medications” [Appendix B])
Assess criteria for starting buprenorphine/naloxone (Suboxone®) or methadone (See “MOUD”
section below).
Consider and treat co-occurring alcohol, benzodiazepine, or alpha-2-agonist (medetomidine or
xylazine) withdrawal.
Anticipated DISCHARGE: Involve care navigator/case management/social work early (if
available) to coordinate follow-up care and ongoing MOUD.
Anticipated ADMISSION: We recommend coordinated policies between ED and inpatient
services to improve transitions of care and post-hospital linkage to care. If available, involving
16 DE OSOC Guidance Document on Opioid Use Disorder in the Emergency Department
addiction medicine and/or psychiatry during the hospital stay can assist in care and coordination
of post-hospital level of care recommendations.
MILD WITHDRAWAL (COWS ≤12):
Symptomatic treatments (Appendix B).
Consider buprenorphine/naloxone (Suboxone) home initiation (Appendix G) or starting
methadone (Appendix C).
Consider checking COWS Q3 hours if at risk for withdrawal or in mild withdrawal.
Opioid agonists (such as hydromorphone) are NOT INDICATED for mild withdrawal.
MODERATE WITHDRAWAL (COWS 13-24):
Symptomatic treatments (Appendix B).
Consider starting buprenorphine/naloxone (Suboxone) or methadone in the ED, if meeting
criteria. See Emergency Department Buprenorphine Initiation Recommendations or Appendix C
for methadone.
Consider checking COWS Q2 hours while in moderate withdrawal.
Opioid agonists (such as hydromorphone) are NOT INDICATED as an initial treatment but may
be considered for worsening or intractable symptoms in the ED.
SEVERE WITHDRAWAL (COWS 25+):
Symptomatic treatments (Appendix B).
Consider starting buprenorphine/naloxone (Suboxone) or methadone in the ED, if meeting
criteria. See Emergency Department Buprenorphine Initiation Recommendations or Appendix C
for methadone.
Opioid agonists (such as hydromorphone) are often needed to control severe symptoms and
pain.
Consider checking COWS Q1-2 hours while in severe withdrawal.
Consider and treat polysubstance withdrawal, such as alpha-2-agonist (medetomidine)
withdrawal.
DISCUSS MEDICATIONS FOR OPIOID USE DISORDER (MOUD)
Below are key talking points related to MOUD that may be helpful to share with patients. To support
clinician preparedness, Appendix A contains frequently asked questions, background information on
some key concepts, and recommended responses to questions that have been asked by patients.
DISCUSS BENEFITS AND POTENTIAL RISKS OF MOUD WITH PATIENT
Significant reduction in risk of overdose or death when stabilized on MOUD.
Reduction in withdrawal symptoms and cravings.
17 DE OSOC Guidance Document on Opioid Use Disorder in the Emergency Department
Small risk of precipitated withdrawal during buprenorphine initiation.
MOUD OPTIONS
Buprenorphine/Naloxone (Suboxone ®):
Buprenorphine is an opioid mu-receptor partial agonist with a long half-life.
The buprenorphine/naloxone combination product (such as Suboxone) is recommended, rather
than the buprenorphine mono-product (such as Subutex), due to decreased risk of diversion or
unintended methods of use.
Naloxone is included in the combination product to decrease the likelihood of diversion or
unintended methods of use and is essentially inactive when the medication is taken sublingually.
Buprenorphine/naloxone (Suboxone) may be started in or from the ED.
Buprenorphine/naloxone (Suboxone) may be prescribed by any physician/prescriber who can
prescribe controlled substances with valid DEA/CDS registrations.
In the past, an X-waiver certificate linked to the standard DEA registration was required–this is
no longer needed. In December 2022 the X-waiver requirements were eliminated with the
Consolidated Appropriations Act of 2023.
Guidelines for starting buprenorphine in the ED can be found in Appendix H and at home in
Appendix G.
Methadone:
Methadone is an opioid receptor full agonist with a long half-life.
Dosing is started low and titrated up over the course of days to weeks.
Patients wishing to start methadone treatment ED must also be referred to an Opioid Treatment
Program (OTP) for ongoing methadone treatment.
Considerations for starting methadone in the ED can be found in Appendix H.
LABORATORY TESTING
Bloodwork is not necessary specifically for MOUD initiation.
Urine toxicology: Urine drug screen, including methadone screen, should be ordered but results
are not required before starting MOUD.
Pregnancy test: Females under 55 years of age with possibility of pregnancy.
PATIENTS DECLINING MOUD
For OUD patients not interested in MOUD after discussion of the potentially life-saving benefits of
MOUD and very high likelihood of returning to opioid use when not on MOUD, resources for ongoing
care and a naloxone rescue kit should be provided. DSAMH provides naloxone “Opioid Rescue Kits” free
of charge.

EMERGENCY DEPARTMENT BUPRENORPHINE INITIATION RECOMMENDATIONS
METHODS OF STARTING BUPRENORPHINE
There are several methods of starting buprenorphine, each with potential risks and benefits. Through
local and regional experience, the high-dose (macro-induction) method is often most conducive for ED
use and will be recommended in these guidelines. Table 1 highlights common methods.
Table 1. Common Buprenorphine Initiation Methods
Method Standard High Dose (macro-induction) Low Dose (micro-induction)
Initial Dose of
Buprenorphine
2-4 mg 16 mg 0.25-1 mg
Benefits • Best for short-acting opioids
(e.g., heroin, oxycodone IR).

Note that heroin is not
frequently found in the
Delaware area’s street opioid
supply.
Safe and effective for fentanyl
withdrawal (if criteria followed),
per studies and local/regional
ED and EMS use.
One or two large doses given,
quick stabilization.
Typically, most conducive to ED
workflow.
No waiting period from last use.
Best for use in hospitalized
patients with a 3–5-day
standardized protocol.
Very low risk of precipitated
withdrawal.
Risks • Requires waiting period from
last use and moderate
withdrawal.
Higher risk of precipitated
withdrawal, especially with
prolonged fentanyl use.
Multiple doses over hours, with
daily adjustments, less
conducive to ED starts.
Requires waiting period from
last use and moderate
withdrawal.
Precipitated withdrawal risk if
criteria not followed.
Requires cross-tapering with an
opioid agonist (continued use of
street opioids through harmreduction approach, or
administration of opioid agonist
in the hospital).
Often confusing process for
patients and clinicians to initiate
and maintain.
References Buprenorphine Quick Start Guide.
Substance Abuse and Mental
Health Services Administration
Accessed October 13, 2025.
https://www.samhsa.gov/sites/de
fault/files/quick-start-guide.pdf
Weimer MB, Herring AA, Kawasaki
SS, Meyer M, Kleykamp BA,
Ramsey KS. ASAM Clinical
Considerations: Buprenorphine
Treatment of Opioid Use Disorder
for Individuals Using High-potency
Synthetic Opioids. J Addict Med.
2023;17(6):632-639.
doi:10.1097/ADM.000000000000
1202
https://pubmed.ncbi.nlm.nih.gov/
37934520/
Suboxone (BuprenorphineNaloxone) self-guided MicroInduction Protocol with CrossTaper. Penn Medicine Center for
Addiction Medicine and Policy.
Accessed October 13, 2025.
https://penncamp.org/wpcontent/uploads/2023/11/suboxo
ne-self-guided-micro-inductionprotocol-with-cross-taper.pdf
Buprenorphine (Bup) Hospital
Start: Low-Dose Bup Initiation
with Opioid Continuation.
19 DE OSOC Guidance Document on Opioid Use Disorder in the Emergency Department
Treat Patients with Substance Use
Disorder on Shift. California
Department of Health Care
Services; 2025. Accessed October
27, 2025.
https://bridgetotreatment.org/ad
diction-treatment/ca-bridge/onshift/
California Department of Health
Care Services; 2024. Accessed
October 13, 2025.
https://bridgetotreatment.org/res
ource/low-dose-buprenorphineinitiation-with-opioidcontinuation/
EMERGENCY DEPARTMENT STARTS
There are 3 groups of patients that can often start buprenorphine in the ED, with goals of symptom
improvement, minimal risk of precipitated withdrawal, and discharge to outpatient follow-up.
Instructions for initiating each of these groups can be found in Appendix H.
Group 1: Opioid withdrawal and meet eligibility criteria below.
Group 2: Recent naloxone resuscitation after opioid overdose.
Group 3: No recent opioids but continue to have cravings and risk of use/overdose.
ED START, GROUP 1: OPIOID WITHDRAWAL AND MEET ELIGIBILITY CRITERIA BELOW
Inclusion Criteria: To minimize the likelihood of precipitated withdrawal, ALL of the following criteria
should be met prior to starting buprenorphine initiation.

Has been at least 24-36 hours since the patient’s last use of fentanyl, or at least 16 hours since
last use of short-acting prescription opioids (such as oxycodone or hydrocodone), AND
Patient has not taken methadone in at least 5 days, AND
COWS score is 12 or higher, AND
Patient subjectively feels very sick from opioid withdrawal and feels ready to start
buprenorphine, AND
Patient has 2 or more objective signs of withdrawal (e.g., tachycardia, sweating, rhinorrhea,
vomiting, diarrhea, enlarged pupils, gooseflesh skin).
Exclusion Criteria
Altered mental status: Patient is significantly altered and cannot give history or consent to
treatment.
Methadone use: If patient has taken methadone within the past 5 days or is receiving
methadone from an opioid treatment program (OTP) facility/clinic, buprenorphine should not
be started in or from the ED. Note that methadone from an OTP may not show up in the
Prescription Monitoring Program (PMP). It is important to ask the patient about any current or
recent methadone use. If unclear, results from a urine drug screen for methadone may be used
along with history from the patient.
20 DE OSOC Guidance Document on Opioid Use Disorder in the Emergency Department
Caution with other sedative use: Alcohol or benzodiazepine use is NOT a contraindication for patients
to be started on buprenorphine. However, the patient should be educated about increased risks due to
a combination of these substances, such as increased sedation.
If meeting criteria, patient can immediately receive buprenorphine/naloxone 16mg/4mg SL to both
treat their withdrawal symptoms and initiate buprenorphine therapy. Additional doses may be
needed. See Appendix H for full ED macrodosing algorithm and information about buprenorphine
precipitated withdrawal.
ED START, GROUP 2: RECENT NALOXONE RESUSCITATION AFTER OPIOID OVERDOSE
Inclusion Criteria: To minimize the likelihood of precipitated withdrawal, ALL of the following criteria
should be met prior to starting buprenorphine initiation.
Patient has received naloxone in the last ~30-45 minutes, AND
Has withdrawal symptoms (COWS 5+), AND
Has NOT taken methadone in the last 5 days, AND
Patient gives consent to receive buprenorphine, THEN,
Patient can immediately receive buprenorphine/naloxone 16mg/4mg SL to both treat their
withdrawal symptoms and initiate buprenorphine therapy. See Appendix H for full ED
macrodosing algorithm.
Note: This is similar to the successful pre-hospital EMS buprenorphine initiation protocol. The risk of
precipitated withdrawal in this group is very low, but there is a time sensitivity to achieve the best
outcomes with buprenorphine initiation. While many Group 2 patients will be coming in via EMS, it is
recommended to work with triage staff to identify these individuals and expeditiously provide
buprenorphine treatment, if indicated.
ED START, GROUP 3: OPIOID ABSTINENCE WITH CRAVINGS
Patients who have been abstinent from opioids and no longer have opioid withdrawal symptoms often
continue to have opioid cravings which put them at risk for opioid use and overdose. This is common in
post-incarceration or post-detoxification/rehabilitation populations; these patients have high rates of
returning to use and overdose mortality. These patients may be started on buprenorphine in the ED and
have outpatient follow-up with an MOUD provider arranged.
Note: Lower starting doses (such as 8mg buprenorphine/naloxone SL) may be considered for this group.
Vivitrol (naltrexone for extended-release injectable suspension) may also be considered for this group if
the patient has been opioid-free for at least 7-10 days.
21 DE OSOC Guidance Document on Opioid Use Disorder in the Emergency Department
HOME START
If your patient is in mild withdrawal or recently used opioids and does not fall into the above groups,
consider providing instructions on starting buprenorphine/naloxone (Suboxone®) at home. The
physician/provider should discuss instructions and the process of starting buprenorphine with the
patient. Several methods of starting buprenorphine have been described (see Table 1 above), including
at home. We have included instructions for one method being used by a local health system. See the
“How to Start Taking Buprenorphine at Home” instruction sheet developed by ChristianaCare. This is
available in Appendix G. With this method, it is also important to prescribe and recommend adjunctive
and symptomatic medications to assist in the treatment of withdrawal prior to starting buprenorphine.
Caution with other sedative use: Alcohol or benzodiazepine use is NOT a contraindication for patients
to start buprenorphine. However, the patient should be educated about increased risks due to a
combination of these substances, such as increased sedation.
HOSPITALIZATION NEEDS
If your patient clearly needs hospitalization for a medical reason or severe withdrawal (opioids or
polysubstance), we recommend coordination with the hospital admitting team and consider
consultation with an Addiction Medicine specialist (if available). Alternative dosing strategies and/or
opioid agonist medications are often needed in the hospital to control severe symptoms.

Prioritize starting and continuing MOUD in the ED or during hospitalization.
Alternative strategies for starting buprenorphine–such as low-dose (micro-inductions) have
been successful in the hospital, with a standardized protocol.
We recommend coordinated policies between ED and inpatient services to improve transitions
of care and post-hospital linkage to care.
SPECIAL POPULATIONS
Pregnancy: Per American College of Obstetricians and Gynecologists (ACOG), the standard of
care for pregnant patients with OUD is buprenorphine or methadone. Consider discussing the
case with obstetrician (OB). Withdrawal symptoms in pregnancy are treated the same as in nonpregnant patients.
Adolescents: FDA guidelines recommend buprenorphine for patients with OUD who are 16 years
of age or older. It is best to consult with Addiction Medicine regarding this population. Home
buprenorphine initiation may be more challenging.
Cirrhosis: Patients with severe liver disease may not metabolize buprenorphine at the same
rates so starting at lower doses may be appropriate. For patients with a history of liver disease
or cirrhosis, discussion with Addiction Medicine consultant or pharmacist is recommended.
22 DE OSOC Guidance Document on Opioid Use Disorder in the Emergency Department
Chronic Pain: For many patients with both chronic pain and OUD, or chronic pain alone,
buprenorphine can be an appropriate alternative to full opioid agonists. Twice daily dosing may
help with pain control. Consider discussion with Addiction Medicine or Pain Management for
patients with OUD treatment complicated by chronic pain.
Dual Diagnosis Patient: Patients struggling with OUD and psychiatric comorbidity face increased
challenges. Buprenorphine is an appropriate medication for OUD in the setting of psychiatric
medications with rare medication interactions.
BUPRENORPHINE PRECIPITATED WITHDRAWAL
If sudden and severe worsening of symptoms after buprenorphine administration:

Give buprenorphine 16 mg SL once IMMEDIATELY (total of 32 mg).
Consider “Adjunctive and Supportive Treatment Options for Opioid Withdrawal” (Appendix B).
Consider ketamine administration:
a. Ketamine can be a helpful adjunct in the treatment of severe opioid withdrawal and
buprenorphine precipitated withdrawal.
b. Initial dose of ketamine 0.3 mg/kg IV slow push over 2 minutes. Alternatively, this dose
may be administered IV over 15 minutes to prolong the effects of the medication.
c. After the initial dose of ketamine, withdrawal symptoms (clinical findings and patient’s
symptoms or COWS score) should be reassessed within 10-15 minutes. If withdrawal
symptoms are not improving, may repeat ketamine dosing at 0.3 mg/kg IV every 15-20
minutes to a maximum dose of 0.9 mg/kg.
d. For patients without an IV, consider ketamine 0.7-1 mg/kg IM.
Reassess in ~30 minutes, consider additional 8-16 mg of SL buprenorphine if not improved (total
of up to 48 mg buprenorphine).
Notes and clarifications:

Buprenorphine precipitated withdrawal (BPW) is often defined as a rapid worsening of opioid
withdrawal symptoms and/or increase in COWS of 5+ within 2 hours (but typically within 30
minutes) after taking buprenorphine.
Gradual increases in withdrawal symptoms and COWS are seen in protracted opioid withdrawal
or polysubstance withdrawal and should NOT be labeled as buprenorphine precipitated
withdrawal.
Risk of precipitated withdrawal is higher in frequent users of large amounts of fentanyl, lower
risk with other opioids or infrequent use.
Risk of precipitated withdrawal is minimized by waiting until the patient is in more significant
withdrawal and using higher starting doses of buprenorphine (macro-induction). Alternatively,
low dose (micro-induction) has a very low risk of BPW (see Table 1 above).
23 DE OSOC Guidance Document on Opioid Use Disorder in the Emergency Department
Consider discussion with Addiction Medicine consultant (if available) in cases of BPW.
MOUD-SPECIFIC REFERENCES:
See here.
ELECTRONIC HEALTH RECORD (EHR) INTEGRATION AND SAMPLE EHR OUD
DISCHARGE SMARTSET
Integration of policies and guidelines into the EHR is recommended for easy access by clinicians and
efficiency of care. Examples of integration include order sets to guide withdrawal care and MOUD
initiation, including resources such as the buprenorphine home start instruction sheet (Appendix G) into
the EHR discharge workflow, or SmartSets such as the example below.
The SmartSet below was shared by TidalHealth Nanticoke. To access: On the Epic User Web in the
Community Library, filter by TidalHealth and search “ED Opioid Use Disorder Discharge”.
Figure 1. TidalHealth ED Opioid Use Disorder Discharge SmartSet

TRANSITIONS OF CARE
OVERVIEW OF CURRENT STATE (SEPTEMBER 2024)
Several hospital partners report using the Delaware Treatment Referral Network (DTRN), formerly
known as Open Beds, to refer patients to local substance use treatment providers. Others contact
treatment providers directly to coordinate the referral or provide a list of local treatment providers and
24 DE OSOC Guidance Document on Opioid Use Disorder in the Emergency Department
resources to patients upon discharge. In some cases, hospitals share information with the treatment
provider, including the patient’s medical record and medications administered in the ER. However, this
information sharing is not standardized or consistent across facilities.
There is some variation among hospitals regarding which staff facilitate referrals and support transitions
of care. At one facility, the physician engages the patient to discuss beginning treatment, then a nurse
makes the referral in DTRN (typically the charge nurse). Only one hospital has a Peer Navigator team
available 24/7; they’re physically located at one facility and provide tele-navigation services for the
other locations. Hospitals report it is difficult for physicians to make referrals because of time
constraints and less familiarity with community resources.
Hospital staff do their best to accommodate patient preferences in terms of treatment provider and
location, depending on availability. They encounter some barriers with referral partners, including lack
of availability, inconsistent MOUD offerings, and misinformation about MOUD initiation best practices
(e.g., primary care providers encouraging urine drug screen prior to buprenorphine initiation).
When discussing gaps related to transitions of care, a major recurring theme is Peer Navigators. Several
hospitals report previously having Peer Navigators employed with grant funding, which has since lapsed.
For those facilities who do have Peer Navigators or other staff to support referrals, there are lapses in
evening and weekend support and a lack of 24/7 coverage was noted as a gap.
Delaware’s Overdose System of Care (OSOC) Acute OUD Stabilization Subcommittee has done significant
work to establish and strengthen relationships between EDs and community treatment providers to
facilitate care transitions. The following OSOC partners have contributed to this foundational work and
committed to supporting patients’ transitions of care.
Table 2. OSOC Referring and Receiving Partners
Referring Organizations Receiving Provider Organizations
Bayhealth
Beebe
ChristianaCare
Kent County EMS
New Castle County EMS
Saint Francis
Sussex County EMS
TidalHealth Nanticoke
Atlantic Family Physicians/La Red
Brandywine
ChristianaCare Family Medicine
ChristianaCare Project Recovery
CORAS
Lotus Recovery Centers
Westside Family Healthcare

DELAWARE RECOMMENDATIONS
Each ED’s internal processes for transitions of care will depend on resources available, such as peer
support or navigators, case management, and social work teams. The recommendations below are
25 DE OSOC Guidance Document on Opioid Use Disorder in the Emergency Department
intended to be flexible and tailored to each individual ED’s needs. Several recommendations rose to the
top during the working group’s discussion, namely the use of care navigators to facilitate warm handoffs
from EDs to outpatient treatment, supporting patient-centered referrals, and broad use of a simple and
flexible electronic referral system.
CARE NAVIGATORS AND PEERS TO FACILITATE WARM HANDOFFS
Care Navigators and Peers to support transitions of care are a top priority among Delaware ED and
treatment provider leaders. Hospitals need a flexible approach to Care Navigators and Peers. Several
hospitals expressed that in an ideal world they would have 24/7 Care Navigator and Peer coverage.
Others don’t have a large enough patient load to support a full-time Care Navigator or Peer but could
greatly benefit from tele-navigation support. Delaware emergency departments are encouraged to
implement Care Navigation and Peers in accordance with the following guidelines:
Care Navigators facilitate referrals from the ED to community treatment for patients with a
substance use disorder, especially those who have experienced a nonfatal overdose and/or have
been initiated on MOUD in the ED.
Referrals follow “warm handoff” best practices, including direct communication with referral
partner, a bridge prescription, pharmacy access assistance, troubleshooting common barriers to
treatment access (e.g., insurance, transportation, childcare, language), and closing the loop with
the patient and referral partner to ensure patient attended their appointment.
Care Navigators develop and implement a discharge and referral checklist and support all care
team members in completing their portion. For example, the Care Navigator may facilitate the
referral and contact the treatment provider for a warm handoff, remind the physician to write a
bridge prescription, remind the nurse to dispense take-home naloxone, and engage a social
worker to coordinate benefits enrollment.
Peers provide support services to patients by identifying hopes, goals and preferences for
treatment and care to be received. The relationship between the peer recovery specialist and
the client served is the foundation on which peer recovery support services and support are
provided. The relationship between the peer and client is respectful, trusting, empathetic,
collaborative, and mutual.
Care Navigator and Peer staffing models are flexible and tailored to the individual needs of each
ED. For example, an ED with a high volume of patients with substance use disorder may need a
24/7 in-person Care Navigation or Peer team, while an ED with a lower volume may need 24/7
access to tele-navigation.
Tele-navigation services are easy to access and supported by necessary technology and
infrastructure. For example, EDs have sufficient tablets to allow for video calls between patients
and tele-navigators and hospital governing boards support credentialing and other
administrative requirements as needed.
26 DE OSOC Guidance Document on Opioid Use Disorder in the Emergency Department
o The Delaware Bridge Clinics can be used to fill the tele-navigation gap while hospitals
are implementing their own programs. Contact information for all Bridge Clinics is
available here: https://www.helpisherede.com/addiction/treatment-andrecovery/bridge-clinics.
If a warm handoff is not feasible, EDs can provide patients with additional resources to support
their transition to community treatment:
o Delaware Bridge Clinics: https://www.helpisherede.com/addiction/treatment-andrecovery/bridge-clinics.
o Help is Here DE: https://www.helpisherede.com/.
o DE Hope Line: 1-833-9-HOPEDE
o Treatment Connection: https://www.treatmentconnection.com/.
The State and health system leadership can support implementing care navigation and warm handoffs in
the following ways:
Funding: The State may facilitate interim funding, such as grant opportunities. For navigation
programs to be sustainable in the long term, health system leadership can allocate ongoing
funding for navigator positions.
Administrative: Health system leadership may help ED teams overcome administrative barriers,
for example, implementing a tele-navigation system or ensuring hospital policy allows for hiring
people with lived experience.
Supervision/employing peers: The State can provide training around key considerations and
strategies for employing and supervising people with lived experience. Health system leadership
can support staff who are supervising people with lived experience (e.g., mentorship, training).
Stigma: Health system leadership (at all levels) must voice strong support for MOUD as an
evidence-based treatment for OUD to fight stigma and misinformation.
Program development: The State and health system leadership can meaningfully engage people
with lived experience (including those who have visited the ED for an OUD-related concern) to
provide input on care navigation planning and implementation.
PATIENT-CENTERED REFERRALS
Referrals from the ED to community treatment involve many clinical and non-clinical considerations,
including insurance coverage, resources for uninsured patients, pharmacy access, transportation, risk
factors, and more. Delaware ED and treatment provider leaders agree these patient-specific factors
must be considered when making referrals. Delaware emergency departments are encouraged to
implement patient-centered referrals in accordance with the following guidelines:
ED teams may consider patients’ insurance status when arranging referrals to community
treatment follow-up availability.
27 DE OSOC Guidance Document on Opioid Use Disorder in the Emergency Department
o Refer uninsured patients to providers on DSAMH’s list of publicly funded addiction
treatment facilities.
o Patients with insurance are referred to providers that accept their insurance. When
using DTRN to make a referral, filter providers by “Payments Accepted” to see those
that accept patient’s insurance. Accepted payments in DTRN are:
▪ Federal military insurance
▪ Medicaid-AmeriHealth
▪ Medicaid-Delaware First Health
▪ Medicaid-Highmark
▪ Medicare
▪ No insurance
▪ Private health insurance
▪ Self-pay
▪ Sliding fee scale
▪ Traditional Medicaid
ED teams and referral partners utilize transportation supports to assist patients in accessing
care. As of October 2025, available transportation supports include:
Table 3. Transportation Supports
Purpose Geography How to Use
DSAMH/Community
Partner Support Unit
(CPSU) Partnership
For individuals following an
interaction with an acute
service setting (e.g., ED, EMS)
to help access an MOUD
appointment.
Statewide Delaware EDs may refer patients to
this transportation resource. To do
so, complete a CPSU Transportation
Request Form and email it to CPSU.
Alternatively, provide the patient
with a CPSU Transportation Referral
Postcard. The patient is then
responsible for calling CPSU to
arrange their ride.
DSAMH’s DTRN
Rideshare (powered by
RoundTrip)
For clients receiving behavioral
health treatment who require
non-emergency
transportation.
Sussex County DSAMH-contracted behavioral
health providers can request the
service via DTRN.
Medicaid NonEmergency Medical
Transportation
(Modivcare)
For Medicaid clients needing
non-emergency transport to
and from a covered medical
service.
Statewide Eligible Delaware Medicaid clients
can request.
28 DE OSOC Guidance Document on Opioid Use Disorder in the Emergency Department
Hospitals work to develop relationships with local pharmacies to facilitate medication access.
When possible, ED leadership works with the hospital’s outpatient pharmacy to establish a
process for patients to get prescriptions filled before they leave the ED.
ED teams do their best to prioritize patients’ language and literacy needs when making referrals,
for example providing referral materials at an appropriate reading level and referring to
treatment providers with multilingual staff or interpreter services.
The State and health system leadership can support implementing the patient-centered referral
guidance in the following ways:
Funding: The State and health system leadership may explore interim funding for transportation
supports, such as grant opportunities. For transportation supports to be sustainable in the long
term, the State may consider increasing capacity to expand DTRN Rideshare.
Pharmacy: Health system leadership can facilitate conversations between ED leadership and
hospital pharmacy leadership to improve processes for ED patients to access medication while
in the ED or upon discharge. Additionally, leadership can engage in relationship-building with
local pharmacies to improve medication access. The State can act as a convener and leverage
pharmacy stakeholders to coordinate this relationship-building.
ELECTRONIC REFERRAL SYSTEM
Referring patients from the ED to community treatment can be facilitated by an electronic referral
system that is easy to use, flexible, and allows for necessary information to be shared between
providers. ED and treatment provider leaders are especially interested in the feedback loop of an
electronic referral system. It’s helpful for both parties to know whether a patient was successfully
connected to care and attended their follow-up appointment.
The Delaware Treatment Referral Network (DTRN), formerly known as Open Beds, is Delaware’s
automated referral network for behavioral health and substance use disorder treatment. The launch of
DTRN360, a care coordination platform, will provide further support and options to providers assisting
patients in accessing care.
Delaware emergency departments are encouraged to utilize the DTRN electronic referral system as the
first line option for making referrals from the ED to community treatment, with the following
considerations:
DTRN allows receiving providers to set their hours for referral receipt, and some chose not to
receive referrals outside business hours. This posed a challenge for EDs, who often need to refer
patients to community treatment during evenings and weekends.
Based on stakeholder input, DSAMH updated the system as follows:
o Users can access the referral form even if it is outside business hours for the
organization/service of interest.
29 DE OSOC Guidance Document on Opioid Use Disorder in the Emergency Department
o DTRN will queue these referrals to ensure they only surface in the receiving provider’s
referral request status page upon the start of their business hours.
o Workflow and “after hours” visual indicators were added to show EDs the provider is
not currently open but will receive the referral request upon opening.
If making a referral through DTRN is not an option, hospitals may do their best to facilitate a
warm handoff via other means (e.g., using the referral pathways/forms developed by OSOC,
calling the community provider, arranging transportation). See referral pathways described in
Transitions of Care, Overview of Current State (September 2024) for more information.
The State and health system leadership can support implementing the electronic referral system
guidance in the following ways:
Awareness and training: The State can continue to raise awareness among relevant ED staff
about the full functionality of DTRN (including forthcoming after hours referrals and DTRN360).
Stakeholder input: The State can continue to collect and be responsive to stakeholder input with
regard to DTRN functionality and features.

DOCUMENTATION AND REIMBURSEMENT (CODING AND BILLING)
Accurate documentation is necessary for statewide surveillance and tracking of OUD care and
overdoses, and to allow for appropriate reimbursement for care provided. Tracking overdoses and OUD
care can assist in the distribution and deployment of public health resources for assistance.
DIAGNOSIS
We recommend using a specific diagnosis reflecting the patient’s presentation. Rather than using a
nonspecific diagnosis such as “Substance Abuse” or “Intoxication,” we recommend applying a more
specific diagnosis code. This allows for accurate documentation and assists in public health surveillance
and response to the opioid crisis.
For example, in a patient with a history of OUD who presented to the ED with an opioid overdose or
opioid withdrawal, a more specific diagnosis would be one (or more) of the following:
Opioid abuse with intoxication (F11.12)
Opioid abuse with withdrawal (F11.13)
Opioid use disorder (F11.90)
Opioid use with intoxication (F11.929)
Opioid use with withdrawal (F11.93)
Opioid overdose (T40.2X1A)
30 DE OSOC Guidance Document on Opioid Use Disorder in the Emergency Department
STARTING MOUD IN THE ED
In 2021, a specific billing code (G2213) was introduced to allow for reimbursement of “Medication
Assisted Treatment (MAT) in the Emergency Department.”
Table 4. G2213 Billing Code Overview
CPT Code Description 2024 wRVU 2024 Total
RVU
G2213 Initiation of medication for the treatment of opioid use disorder in
the emergency department setting, including assessment, referral
to ongoing care, and arranging access to supportive services.
1.3 1.8
This code (G2213) will cover the resource costs involved with initiation of medication for the treatment
of opioid use disorder and referral for follow-up care. G2213 is an add-on code that can be assigned in
addition to the ED E/M code. It also includes payment for assessment, referral to ongoing care, followup after treatment begins, and arranging for access to supportive services. Note that this code is not to
be used for giving a patient a dose of naloxone.
Documentation should include:
Indications for medications for opioid use disorder (MOUD), also referred to as medication
assisted treatment (MAT).
Specific medication employed.
Follow-up process.
Diagnosis of opioid use disorder (OUD).
Reference:
Medication Assisted Treatment (MAT) FAQs. American College of Emergency Physicians.
Updated February 2024. Accessed May 2025. Available at:
https://www.acep.org/administration/reimbursement/reimbursement-faqs/medicationassisted-treatment-mat-faqs/
Additional information obtained from the Ventra Health coding team. Consider contacting your
facility’s coding/billing team for additional recommendations.
REDUCING OVERDOSE RISK, COMPLICATIONS, AND HARM FROM OPIOID USE
DISORDER
Even if a patient is not ready to stop using substances, there are ways to minimize the negative health,
social, and legal impacts associated with drug use. Stopping the use of drugs and getting into treatment
is the safest option, but can be extremely difficult due to withdrawal, cravings, and psychosocial
31 DE OSOC Guidance Document on Opioid Use Disorder in the Emergency Department
stressors. The following are recommendations for reducing stigma and “meeting people where they are”
if they are not yet ready to stop using.
Naloxone kits: Naloxone “Opioid Rescue Kits” are available free of charge from DSAMH. Kits
include Narcan®, CPR face mask, and referral resources for ongoing treatment.
Safer injection: Brandywine Counseling & Community Services’ syringe services program (SSP)
offers safer injection and disease prevention resources.
o https://brandywinecounseling.com/ssp/
o 302-588-0452
Drug checking test strips: Patients may use fentanyl or xylazine test strips to test for the
presence of these substances in their drugs.
OpiRescue Delaware: Free smartphone application that provides individuals and organizations
resources to prevent and recognize overdoses, perform overdose reversals, access naloxone,
report naloxone use, and more. It’s available for download on all Android and Apple devices.
Never Use Alone: National toll-free hotline for individuals to call when they are using drugs
alone. Operators are people with lived experience who collect location and contact information
from the caller and contact emergency services in the event of unresponsiveness. Available 24
hours a day, 7 days a week, 365 days a year.
o www.neverusealone.com
o 800-484-3731 or 877-696-1996
Consider sharing safer use tips, such as:
o Start low, go slow. Use a test shot to determine the strength and effects.
o Don’t use alone, when possible.
▪ Take turns using when in a group.
▪ If using alone is the only option and a trusted friend or family member is
available, ask them to monitor for signs of overdose and respond if necessary.
Otherwise, use the Never Use Alone hotline.
o Use one drug at a time. Using multiple substances at once increases the risk of
overdose.
o Have an overdose plan and keep naloxone nearby and easily accessible.

CONCLUSION
This Guidance Document represents a unified, evidence-based framework to strengthen the
identification, management, and continuity of care for patients with OUD in Delaware EDs. Developed
through collaboration among clinicians, health systems, and state partners, it provides clear, adaptable
recommendations to promote standardized practices across screening, patient engagement, medication
initiation, and transitions of care. By embedding these approaches into daily ED operations and aligning
them with statewide systems and resources, Delaware EDs can ensure every encounter becomes an
opportunity for stabilization, connection, and recovery.
32 DE OSOC Guidance Document on Opioid Use Disorder in the Emergency Department
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MOUD-SPECIFIC REFERENCES
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emergency department or emergency out-of-hospital setting: A mixed-methods systematic
review. Am J Emerg Med. 2025;88:12-22. https://pubmed.ncbi.nlm.nih.gov/39577213/
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opioid use disorder. West J Emerg Med. 2024;25(5):668-674.
https://pmc.ncbi.nlm.nih.gov/articles/PMC11418868/
Weimer MB, Herring AA, Kawasaki SS, Meyer M, Kleykamp BA, Ramsey KS. ASAM clinical
considerations: buprenorphine treatment of opioid use disorder for individuals using high-
35 DE OSOC Guidance Document on Opioid Use Disorder in the Emergency Department
potency synthetic opioids. J Addict Med. 2023;17(6):632-639.
https://pubmed.ncbi.nlm.nih.gov/37934520/
Treat patients with opioid use disorder on shift: Buprenorphine Emergency Department Quick
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https://bridgetotreatment.org/addiction-treatment/ca-bridge/on-shift/
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department among patients using fentanyl and other opioids. JAMA Netw Open.
2023;6(3):e231572. https://pmc.ncbi.nlm.nih.gov/articles/PMC9984967/
Checkley L, Ly J, Geier C, LeSaint KT. Buprenorphine initiation and rates of associated
precipitated withdrawal in patients with fentanyl use in an urban emergency department. Am J
Emerg Med. 2025;88:152-155. https://pubmed.ncbi.nlm.nih.gov/39626454/
Huo S, Heil J, Salzman MS, et al. Emergency department utilization of the methadone “72-hour
rule” to bridge or initiate and link to outpatient treatment. Am J Emerg Med. 2025;89:209-215.
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Spadaro A, Faude S, Perrone J, et al. Precipitated opioid withdrawal after buprenorphine
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36 DE OSOC Guidance Document on Opioid Use Disorder in the Emergency Department
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adulteration: a multicenter study from Philadelphia, PA. J Addict Med. Published online August
1, 2025. https://pubmed.ncbi.nlm.nih.gov/40747932/
Huo S, London K, Murphy L, et al. Notes from the field: suspected medetomidine withdrawal
syndrome among fentanyl-exposed patients – Philadelphia, Pennsylvania, September 2024-
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https://pmc.ncbi.nlm.nih.gov/articles/PMC12045483/
37 DE OSOC Guidance Document on Opioid Use Disorder in the Emergency Department
APPENDIX A. BUPRENORPHINE FREQUENTLY ASKED QUESTIONS AND SUGGESTED
RESPONSES
MEDICATION EDUCATION
What is buprenorphine?

Buprenorphine [byoo-pruh-nor-feen], sometimes called “bupe/bup”, is an opioid receptor
partial agonist medication that can help treat opioid use disorder. It has a high receptor
affinity, so it can displace opioids (such as fentanyl) from the opioid receptors.
Buprenorphine is available as Subutex® (buprenorphine only) and Suboxone® (a
combination medication that includes buprenorphine and naloxone).
Naloxone is included in Suboxone® to discourage inappropriate use or diversion of the
medication. The naloxone is essentially inactive when Suboxone® is taken sublingually.
Note that while Suboxone® is sometimes sold on the street, most people who buy it seem to
be trying to treat themselves and trying to get off fentanyl. We can help get them into
treatment! People don’t get “high” from sublingual Suboxone®.

It says “naloxone” on the packaging. Why are you giving me more Narcan®? I thought this was
going to help.
Response:

Suboxone® contains both buprenorphine and naloxone, but the naloxone (Narcan®) isn’t
active when you take the medicine under your tongue.
Naloxone is included as a safeguard to prevent dissolving the strips to inject – the Narcan®
will block any euphoric or “high” feelings if someone tried to inject it.

I can’t take Suboxone®, it gives me headaches. I can only take Subutex®.
Response:

We can only give Suboxone® to help treat your opioid use and withdrawal, but I can give you
a dose of Tylenol to help if you get a headache.
Staying well hydrated and taking over-the-counter medicines like Tylenol or ibuprofen can
help with headaches.
Sometimes patients do have headaches initially, but the headaches typically get better over
time.

What happens if I use again after taking Suboxone®/buprenorphine?
Response:

If you use again after taking buprenorphine (Suboxone®), the buprenorphine in your system
will reduce the effect of opioids (e.g., fentanyl) taken.
But the goal of Suboxone® is to treat withdrawal, control your cravings, and help prevent
you from feeling the need to use.
38 DE OSOC Guidance Document on Opioid Use Disorder in the Emergency Department

I won’t be able to drink alcohol if I take Suboxone®.
Response:

Buprenorphine is not like Antabuse® (disulfiram). You could still drink alcohol, but you may
get sleepier if you’re on buprenorphine.
We recommend being very careful if you’re also drinking alcohol or taking other sedating
medicines (like benzodiazepines). Don’t drive and please talk with your doctor/prescriber
about it.
PRECIPITATED WITHDRAWAL

What is precipitated withdrawal?

Precipitated withdrawal (also known as “precip”) is a sudden worsening of withdrawal
symptoms after being given an opioid antagonist (e.g., naloxone) or partial agonist (e.g.,
buprenorphine) that displaces a full opioid agonist (e.g., fentanyl or methadone) from the
opioid receptors.
Buprenorphine precipitated withdrawal occurs because buprenorphine can displace the full
agonist (e.g., fentanyl), but can only partially stimulate the opioid receptor.
Interestingly, the risk of precipitated withdrawal is low after an opioid overdose and
naloxone. There are several theories of why this is the case, including a lower opioid
tolerance which caused the overdose.

I/my friend had precipitated withdrawal after taking Suboxone®. I don’t want to go into
“precip”.
Response:

I understand that precipitated withdrawal feels terrible, and we don’t want you going into
“precip” either.
Over the years we’ve found new ways to start Suboxone® and avoid precipitated
withdrawal.
After getting Narcan® for an overdose we have a window of time when you can take
Suboxone®, avoid precipitated withdrawal, and start to feel better. We’re in that window
right now.
If you start to feel worse, we can give more Suboxone® and other medications to help you
feel better.
INEFFECTIVE MEDICATION

I’ve taken Suboxone® before, years ago, without success.
Response:

The dosing of the medication has changed, and we are using a much higher dose to keep
you out of withdrawal and to control your cravings.
39 DE OSOC Guidance Document on Opioid Use Disorder in the Emergency Department

My significant other/friend had Suboxone® and said it didn’t work.
Response:

The dosing of the medication has changed, and we are using a much higher dose to keep
you out of withdrawal and to control your cravings.
STIGMA-RELATED

Isn’t Suboxone®/buprenorphine just replacing one drug for another?
Response:

Suboxone® is a medicine that can be taken at a specific prescribed dose to control
withdrawal symptoms and cravings.
Suboxone® partially plugs the opioid receptors to help you feel better. It can help you cut
down and stop using and help you move toward recovery.
Opioid use disorder/addiction is a medical condition/disease—like high blood pressure or
diabetes. We give medicine to treat high blood pressure and diabetes—taking Suboxone® to
treat opioid use disorder is similar, and it can help treat the medical condition of opioid
addiction.

I don’t want to be on Suboxone®/buprenorphine forever.
Response:

Starting Suboxone® now can help you stop using drugs/fentanyl, but you don’t have to be
on Suboxone® forever.
Suboxone® can help treat your withdrawal, control your cravings, and help you move
toward recovery.
If you start Suboxone® now and you want to stop taking it in the future, your medical
provider can help you wean the dose down over time to keep you comfortable.

Denial, e.g., “I didn’t take anything” or “I’m not taking that stuff.”
Response:

Note: Sometimes patients will deny using opioids. If their clinical picture was consistent with
an opioid overdose, it was reversed with naloxone, and they’re having opioid withdrawal
symptoms, you can still offer Suboxone®. Instead of challenging them, consider saying
something like the following.
I am really glad you didn’t die tonight. I am happy we were able to give you medicine to get
you breathing again. A lot of people in your situation don’t feel well and I have a medicine
that can help you with that. We can get you started on Suboxone® right now, so you don’t
have to go through this again. Can I give you this medicine to help you start feeling better?
Also remember that many people with opioid use disorder will need to hear this several
times before they agree to treatment (research says it takes between 3 and 8 attempts at
treatment before recovery). You can help the patient feel better and move toward recovery.
40 DE OSOC Guidance Document on Opioid Use Disorder in the Emergency Department
OTHER CONCERNS

With all the other stuff in street drugs now (medetomidine and sedating adulterants), how
can I get started on treatment?
Response:

Adulterants in the street drugs (such as medetomidine) can make starting treatment more
difficult, but treatment is still possible, and we would like to help.
With medetomidine, we often see:
o Overdose: Very sleepy/sedated and low heart rates.
o Withdrawal: High blood pressure, high heart rates, shaking, and a lot of vomiting.
Talk with your doctor/prescriber about giving other medications to help treat your
withdrawal symptoms. Examples of medications that could be given are clonidine,
tizanidine, and ondansetron.

I’m on probation and this will result in people knowing I violated my probation, and I’ll go
back to jail.
Response:

We’re here to help, not to get you in trouble. We don’t report to probation or parole; it is all
confidential patient medical information.

Will I get into trouble if I don’t follow up at the clinic?
Response:

No, you will not get into any trouble if you do not go to the clinic. We’re here to help. This is
an opportunity for you to get help if and when you want it. We do encourage you to go for
follow-up.

Will taking this medication now mess up my intake schedule/appointment at rehab?
Response:

No this will not change anything with an intake that you already have scheduled. Recovery
takes time. Suboxone® can help you feel better until you have your appointment and
continue to work on your recovery.

I live out of state and I’m visiting Delaware. How am I going to make it to one of these
appointments?
Response:

If you are still in the area for a few days, go for intake and they can help you to find a clinic
near home to continue treatment.
You can also visit www.HelpIsHereDE.com or www.FindTreatment.gov, or call 1-800-662-
HELP or 988 for assistance in finding substance use treatment near your home.
41 DE OSOC Guidance Document on Opioid Use Disorder in the Emergency Department
TRANSPORTATION ISSUES

I don’t have transportation to get to/from an appointment.
Response:

See table below for transportation resources.
Purpose Geography How to Use
DSAMH/Community
Partner Support Unit
(CPSU) Partnership
For individuals following an
interaction with an acute
service setting (e.g., ED, EMS)
to help access an MOUD
appointment.
Statewide Delaware EDs may refer patients to
this transportation resource. To do
so, complete a CPSU Transportation
Request Form and email it to CPSU.
Alternatively, provide the patient
with a CPSU Transportation Referral
Postcard. The patient is then
responsible for calling CPSU to
arrange their ride.
DSAMH’s DTRN
Rideshare (powered by
RoundTrip)
For clients receiving behavioral
health treatment who require
non-emergency
transportation.
Sussex County DSAMH-contracted behavioral
health providers can request the
service via DTRN.
Medicaid NonEmergency Medical
Transportation
(Modivcare)
For Medicaid clients needing
non-emergency transport to
and from a covered medical
service.
Statewide Eligible Delaware Medicaid clients
can request.

Should I call 911 if I can’t get transportation to the clinic?
Response:

No – 911 does not provide transportation to clinic or office appointments, it is for medical
emergencies only.
INSURANCE/PAYMENT

I don’t have any insurance.
Response:

You do not need insurance for the intake appointment. Go to the appointment and the staff
will assist you to get the resources that you need.
If you don’t have health insurance, you may be eligible for publicly funded addiction
treatment services through DSAMH.
You can find out more about publicly funded treatment by calling the Delaware Hope Line
(1-833-9-HOPEDE) or visiting your local DSAMH Bridge Clinic:
42 DE OSOC Guidance Document on Opioid Use Disorder in the Emergency Department
o Bridge Clinic New Castle County Fernhook Building – 14 Central Ave., New Castle,
DE 19720
▪ Hours: Daily, 8:00am to 11:30pm
▪ Phone: 302-288-0230
o Bridge Clinic New Castle County Hope Center – 365 Airport Rd., New Castle, DE
19720
▪ Hours: M-F, 8:00am to 4:30pm and Sat, 8:00am to 4:30pm
▪ Phone: 302-544-6815
o Bridge Clinic Kent County James W. Williams State Service Center – 805 River Rd.,
3rd Floor, Dover, DE 19901
▪ Hours: M-F, 8:00am to 4:30pm
▪ Phone: 302-857-5060
o Bridge Clinic Sussex County Thurman Adams State Service Center – 546 S. Bedford
St., Georgetown, DE 19947
▪ Hours: M-F, 8:00am to 4:30pm
▪ Phone: 302-515-3310

APPENDIX B. ADJUNCTIVE AND SUPPORTIVE TREATMENTS FOR WITHDRAWAL

Nausea and Vomiting
o Ondansetron 4 mg PO/IV every 4-6 hours as needed
o ProMETHazine 25 mg PO every 4-6 hours as needed
o ProChLORperazine 10 mg IM every 6 hours as needed
Anxiety and Restlessness
o CloNIDine 0.2-0.3 mg PO every 6 hours as needed (hold if SBP<110mmHg or HR<55)
▪ Note: Clonidine can mitigate the adrenergic effects of opioid withdrawal and
contribute to the control of alpha-2-agonist (medetomidine or xylazine)
withdrawal. Higher doses of clonidine (at least 0.3 mg) and more frequent
dosing may be needed in patients experiencing medetomidine withdrawal.
▪ See “Medetomidine (alpha-2-agonist) Withdrawal” section below
o CloNIDine 0.3 mg/24 hr Transdermal film, extended release
▪ Note: Oral clonidine AND clonidine transdermal film may be ordered in patients
experiencing medetomidine withdrawal. Clonidine transdermal film has a
prolonged time frame (2+ days) to achieve therapeutic levels.
▪ See “Medetomidine (alpha-2-agonist) Withdrawal” section below
o HydrOXYzine 25-50 mg PO every 8 hours as needed
o Gabapentin 300 mg PO every 8 hours as needed
o Benzodiazepines may be considered, if needed, but are considered second-line
Pain, Body Aches, or Muscle Spasm
o TiZANidine 4 mg PO every 6-8 hours as needed for muscle spasm
o Note: Tizanidine, an alpha-2-agonist medication, can contribute to the control of
medetomidine withdrawal symptoms.
o Ibuprofen 600 mg PO every 6-8 hrs as needed for pain
o Ketorolac 15 mg IV/IM every 4-6 hrs as needed for pain
o Acetaminophen 650 mg PO every 4-6 hrs as needed for pain
o Dicyclomine 20 mg PO/IM every 6 hours as needed for abdominal cramping
o Methocarbamol 500 mg IV/PO every 8 hours as needed for severe muscle aches
Diarrhea
o Loperamide 2 mg PO every 2 hours as needed (maximum 16 mg in 24 hours)
Withdrawal-Associated Akathisia
o Ropinirole 0.25-1 mg PO every 8 hours as needed
44 DE OSOC Guidance Document on Opioid Use Disorder in the Emergency Department
Medetomidine (alpha-2-agonist) Withdrawal:
o Medetomidine withdrawal often causes significant hypertension and tachycardia,
shaking/muscle tremor, nausea/vomiting, and agitation, sometimes with decreased
verbal responsiveness and catatonic appearance.
o Polysubstance withdrawal: Patients should be treated for both medetomidine
withdrawal and fentanyl withdrawal (based on prevalence of medetomidine in the
community/region).
o NOTE: Medetomidine withdrawal typically starts earlier than fentanyl withdrawal.
o As stated above, consider the following alpha-2-agonists early in the course of
medetomidine withdrawal: Clonidine (if able to tolerate oral medications) and the
clonidine transdermal patch, and tizanidine.
▪ Per expert opinion and regional experience: Consider higher doses of clonidine
(0.3-0.6 mg PO and transdermal) for medetomidine withdrawal.
o Some health systems have recommended or considered other alpha-2-agonists, such as
guanfacine or sublingual dexmedetomidine.
o For severe medetomidine withdrawal: Dexmedetomidine (Precedex) infusion with
higher starting rates and rapid titration should be considered.
▪ Per expert opinion and regional experience: Consider dexmedetomidine starting
rates of at least 0.5 mcg/kg/hr. Loading doses (such as 1 mcg/kg over 10+
minutes) may also be considered for severe medetomidine withdrawal.
45 DE OSOC Guidance Document on Opioid Use Disorder in the Emergency Department
APPENDIX C. CONSIDERATIONS FOR METHADONE IN THE ED
We encourage hospitals to develop policies allowing for methadone to be started in the ED as a method
of MOUD. Examples of policies to consider are included below.
For patients NOT ENROLLED in a certified Opioid Treatment Program (OTP):
Methadone may be ordered and administered in the ED, but can NOT be prescribed for the
treatment of OUD. In the ED:
o Consider EKG to evaluate for QTc prolongation, especially if the patient is on
medications which could potentially prolong the QTc.
o For patients in opioid withdrawal (COWS 5+) who are interested in starting methadone,
up to 30 mg of methadone may be given to help reduce the symptoms of opioid
withdrawal.
▪ If needed, an additional 10mg of oral methadone may be given for a total of up
to 40 mg on day 1.
o Patients must be referred to an OTP for ongoing methadone treatment; however, if
unable to follow-up in a timely manner (such as over a weekend), the patient may
receive daily dosing of up to 30 mg of methadone daily in the ED for up to three (3)
days.
For patients ENROLLED in a certified Opioid Treatment Program (OTP):
There are situations in which giving the patient’s regular methadone dose may be indicated,
examples include:
o For patients being treated for medical conditions–other than primarily opioid
withdrawal–that, as a result, are unable to receive their daily scheduled methadone at
their OTP.
o During declared states of emergency in which the OTP is unable to provide the
scheduled dose.
In these cases, and depending on facility policy, a physician/provider or pharmacist must contact
the patient’s OTP to verify enrollment in the OTP and the following prior to ordering or
dispensing the patient’s regular methadone dose:
o Name, location, and phone number of OTP, and name of verifying OTP staff member.
o Patient’s dose and date of last administered dose.
o If the last dose was greater than 72 hours prior, then the patient should be referred
back to OTP for treatment.
If verification is unable to be obtained, up to 30 mg of methadone may be ordered and
administered.
Patients presenting solely for missing their OTP dose, outside of a declared state of emergency,
should not be provided methadone, and should be referred back to their OTP.
46 DE OSOC Guidance Document on Opioid Use Disorder in the Emergency Department
APPENDIX D. ED DISCHARGE CHECKLIST
All of the following should be reviewed or completed by the treating physician/provider.
 Plan for follow-up with MOUD provider:
o Involve Care Navigator/Social Work/Case Management (if available) to assist with
follow-up planning, OR
o Use referral pathway to assist with follow-up planning.
o Provide follow-up appointment information and location in the patient’s discharge
instructions.
 Prescription Drug Monitoring Program (PDMP) review:
o Check PDMP for active opioid or benzodiazepine prescriptions. If found, the patient
should be counseled on the increased risks associated with taking several potentially
sedating medications. This is NOT a contraindication to prescribing buprenorphine.
 Provide naloxone rescue kit (preferred) or write prescription for naloxone 4mg/0.1mL nasal
spray.
 For patients starting buprenorphine/naloxone (Suboxone):
o Recommended prescription: Buprenorphine/naloxone (Suboxone) 8mg/2mg SL film.
Take 1 SL film BID. Dispense # fifteen (15) films. Note: For patients who use large
amounts of fentanyl daily, three-times per day dosing (24 mg buprenorphine daily) may
be considered to control symptoms and cravings.
o Home Starts: Physician/provider discusses the process with the patient and provides
instruction sheet (“How to Start Taking Buprenorphine at Home”).
o Prescribe or recommend adjunctive and supportive medications for opioid withdrawal,
such as ondansetron, clonidine, tizanidine, and ibuprofen.
 For patients starting methadone:
o Consider writing prescriptions for adjunctive and supportive treatments for opioid
withdrawal, such as ondansetron, clonidine, tizanidine hydroxyzine, loperamide, and
ibuprofen.
 Discharge instructions
o Include system-specific discharge instructions related to MOUD, treatment locations,
opioid use disorder, naloxone use, and/or harm reduction.
o Patients may continue to have cravings to use opioids. It is helpful to inform patients
what they may experience as they get stabilized on their dose, but that they will
gradually feel better.
47 DE OSOC Guidance Document on Opioid Use Disorder in the Emergency Department
APPENDIX E. CHECKLIST TO EVALUATE FOR OPIOID USE DISORDER (OUD)
While an OUD diagnosis is often clear based on a brief conversation with the patient and review of
records, the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) includes
specific criteria for OUD diagnosis. Select all that apply:
 Opioids are often taken in larger amounts or over a longer period of time than intended.
 There is a persistent desire or unsuccessful efforts to cut down or control opioid use.
 A great deal of time is spent in activities necessary to obtain the opioid, use the opioid, or
recover from its effects.
 Craving, or a strong desire to use opioids.
 Recurrent opioid use resulting in failure to fulfill major role obligations at work, school or home.
 Continued opioid use despite having persistent or recurrent social or interpersonal problems
caused or exacerbated by the effects of opioids.
 Important social, occupational or recreational activities are given up or reduced because of
opioid use.
 Recurrent opioid use in situations in which it is physically hazardous.
 Continued use despite knowledge of having a persistent or recurrent physical or psychological
problem that is likely to have been caused or exacerbated by opioids.
 Tolerance, as defined by either of the following: (a) a need for markedly increased amounts of
opioids to achieve intoxication or desired effect (b) markedly diminished effect with continued
use of the same amount of an opioid. (Note: This criterion is not considered to be met for
individuals taking opioids solely under appropriate medical supervision)
 Withdrawal, as manifested by either of the following: (a) the characteristic opioid withdrawal
syndrome (b) the same (or a closely related) substance are taken to relieve or avoid withdrawal
symptoms. (Note: This criterion is not considered to be met for individuals taking opioids solely
under appropriate medical supervision)
Total number of boxes checked: _ Severity of OUD (# of boxes checked): Mild = 2-3 Moderate = 4-5 Severe = 6+ 48 DE OSOC Guidance Document on Opioid Use Disorder in the Emergency Department APPENDIX F. CLINICAL OPIATE WITHDRAWAL SCALE (COWS) For each item, circle the number that best describes the patient’s signs or symptoms. Rate on just the apparent relationship to opiate withdrawal. For example, if heart rate is increased because the patient as jogging just prior to assessment, the increased pulse rate would not add to the score. Resting Pulse Rate: beats/minute measured after
patient is sitting or lying for one minute
0 pulse rate 80 or below
1 pulse rate 81-100
2 pulse rate 101-120
4 pulse rate greater than 120
Gastrointestinal Upset: over last 1/2 hour
0 no GI symptoms
1 stomach cramps
2 nausea or loose stool
3 vomiting or diarrhea
5 multiple episodes of diarrhea or vomiting
Sweating: over last 1/2 hour not accounted for by room
temperature or patient activity
0 no report of chills or flushing
1 subjective report of chills or flushing
2 flushed or observable moistness on face
3 beads of sweat on brow or face
4 sweat streaming off face
Tremor: observation of outstretched hands
0 no tremor
1 tremor can be felt, but not observed
2 slight tremor observable
4 gross tremor or muscle twitching
Restlessness: Observation during assessment
0 able to sit still
1 reports difficulty sitting still, but is able to do so
3 frequent shifting or extraneous movements of
legs/arms
5 unable to sit still for more than a few seconds
Yawning: Observation during assessment
0 no yawning
1 yawning once or twice during assessment
2 yawning three or more times during assessment
4 yawning several times/minute
Pupil size:
0 pupils pinned or normal size for room light
1 pupils possibly larger than normal for room light
2 pupils moderately dilated
5 pupils so dilated that only the rim of the iris is
visible
Anxiety or Irritability:
0 none
1 patient reports increasing irritability or
anxiousness
2 patient obviously irritable or anxious
4 patient so irritable or anxious that participation in
the assessment is difficult
Bone or Joint Aches: if patient was having pain previously,
only the additional component attributed to opiate
withdrawal is scored
0 not present
Gooseflesh Skin:
0 skin is smooth
3 piloerection of skin can be felt or hairs standing
up on arms
49 DE OSOC Guidance Document on Opioid Use Disorder in the Emergency Department
1 mild diffuse discomfort
2 patient reports severe diffuse aching of
joints/muscles
4 patient is rubbing joints or muscles and is unable
to sit still because of discomfort
5 prominent piloerection
Runny nose or tearing: Not accounted for by cold –
symptoms or allergies
0 not present
1 nasal stuffiness or unusually moist eyes
2 nose running or tearing
4 nose constantly running or tears streaming down
cheeks
Total Score : __
The total score is the sum of all 11 items:
● 5 – 12 = mild
● 13 – 24 = moderate
● 25 – 36 = moderately severe
● > 36 = severe
50 DE OSOC Guidance Document on Opioid Use Disorder in the Emergency Department
APPENDIX G: BUPRENORPHINE HOME INITIATION
For patients with mild withdrawal symptoms (COWS < 12) who wish to start buprenorphine:

Physician/provider will discuss home initiation with the patient and patient will be instructed to
follow the “How to Start Taking Buprenorphine at Home” instruction sheet (following page).
Counsel patients regarding the importance of feeling extremely sick before starting, allowing the
buprenorphine to be absorbed under their tongue, and not to swallow the buprenorphine.
At discharge, review the “ED Discharge Checklist” (Appendix D) to include referral information,
instructions, and give the following prescriptions:
a. Buprenorphine/naloxone (Suboxone®) 8mg/2mg SL film; 1 film SL two times a day (16
mg buprenorphine daily) until follow-up (dispense #15 films). Note: For patients who
use large amounts of fentanyl daily, three-times per day dosing (24 mg buprenorphine
daily) may be considered.
b. Naloxone take-home kit (preferred) or prescription: naloxone 4mg/0.1mL nasal spray
(dispense # 1).
c. Adjunctive and Supportive medications to improve withdrawal symptoms during the
home initiation process, such as ondansetron, clonidine, acetaminophen, ibuprofen,
tizanidine, loperamide.
i. Alpha-2-agonist (medetomidine) withdrawal: Consider placing a clonidine
transdermal patch in the ED and providing prescriptions for oral clonidine and
tizanidine to help mitigate the effects of alpha-2-agonist withdrawal (if
applicable)
Discharge information should include information about medications, risk of overdose, harm
reduction resources, MOUD provider information and appointment or appointment time frame,
and instructions for home initiation, if applicable.
Patients should leave the ED with an appointment or clear appointment time frame established,
coordinated with Care Navigator/Social Work/Case Management (if available). Care
Navigator/Social Work/Case Management (if available) will provide this information to ED
caregivers so it may be added to patient discharge instructions
a. Appointment for opioid use disorder treatment
i. ED provider may coordinate with Care Navigator/Social Work/Case
Management (if available) to determine outpatient treatment location where
patient is being referred.
ii. Ensure patient’s current phone number is on record.
51 DE OSOC Guidance Document on Opioid Use Disorder in the Emergency Department
52 DE OSOC Guidance Document on Opioid Use Disorder in the Emergency Department
APPENDIX H. INSTRUCTIONS FOR STARTING BUPRENORPHINE IN THE ED
Follow “Buprenorphine Initiation in the ED Algorithm” (following page) and consider “Adjunctive
and Supportive Treatment Options for Opioid Withdrawal” (see below).
a. This method of starting buprenorphine is considered a “macro” or “high dose” initiation.
To reduce the risk of precipitated withdrawal, it is important that the patient meet all
initiation criteria, including:
i. At least 24-36 hours since last use of fentanyl (larger reported amounts of daily
fentanyl use, such as 1-2+ bundles/day typically require longer waiting times)
ii. No methadone in at least 5 days
iii. COWS of at least 12
If patient meets criteria, administer buprenorphine/naloxone (Suboxone) 8mg/2mg SL x 2 (total
of 16 mg buprenorphine).
Wait at least 30 minutes. Does the patient feel subjective improvement in symptoms?
a. If mild or no improvement, administer an additional dose of buprenorphine/naloxone
16mg/4mg SL (for a total dose of 32 mg buprenorphine).
If no response after 32mg consider discussion with Addiction Medicine consultant (if available).
Once significant improvement demonstrated:
a. Coordinate with Care Navigator/Social Work/Case Management (if available) for
discharge and follow-up planning.
b. Complete “ED Discharge Checklist” (below).
c. Check PMP for active opioid or benzodiazepine prescriptions. If found, the patient
should be counseled on the potential risks of combining these medications (such as
increased sedation).
Provide prescriptions for:
a. Buprenorphine/naloxone 8mg/2mg SL film; 1 film SL two times a day (16 mg
buprenorphine daily) until follow-up (dispense #15 films). Note: For patients who use
large amounts of fentanyl daily, three-times per day dosing (24 mg buprenorphine daily)
may be considered.
b. Adjunctive and Supportive medications, such as ondansetron, clonidine,
acetaminophen, ibuprofen.
c. Alpha-2-agonist (medetomidine) withdrawal: Consider placing a clonidine transdermal
patch in the ED and providing prescriptions for oral clonidine and tizanidine.
d. Naloxone take-home rescue kit (preferred) or prescription for naloxone 4mg/0.1mL
nasal spray (dispense # 1).
Caution with other sedative use: Alcohol or benzodiazepine use is NOT a contraindication for patients
to be started on buprenorphine. However, the patient should be educated about increased risks due to
a combination of these substances, such as increased sedation

APPENDIX C: DEFINITIONS AND ROLE CLARIFICATIONS, DEVELOPED BY DSAMH
Title Scope of Work
Clinician A Behavioral Health Clinician is a mental health professional who assesses, diagnoses, and/or
treats individuals with mental health disorders and behavioral problems using therapeutic
interventions. They work with individuals, families, and groups, employing various techniques
to help clients manage symptoms, develop coping skills, and improve their overall well-being.
Various levels of license, certification, and other accreditation:

Licensed/Board certified (may diagnose and/or treat):
o Psychologist (PsyD)
o LCSW (Licensed Clinical Social Worker)
o MSW (Master Social Worker)
o LPCMH (Licensed Professional Counselor in Mental Health)
o CDP (Chemical Dependency Professional)
Certifications (oftentimes not tied to post-secondary education requirements):
o CADC
College degrees in related field without a license may perform some clinical functions
(may not diagnose or treat, but can assist in various parts of care management under
guidance/supervision of licensed individual):
o Master’s Level unlicensed
o Bachelor’s Level unlicensed
Case Manager
Other titles:
Discharge planner
Care navigator
Case Managers help individuals navigate and access various services and resources to meet
their needs. They play a crucial role in coordinating care plans, assessing client needs, and
connecting individuals with appropriate support systems. Case managers work in a variety of
settings, including healthcare, social services, and legal fields. Often an undergraduate degree
or higher is required of the role.
Key responsibilities of a Case Manager:
Assessment: Evaluating a person’s needs, challenges, and resources.
Planning: Developing individualized care or service plans.
Coordination: Connecting individuals with appropriate resources and services.
Advocacy: Representing clients’ interests and advocating for their needs.
Communication: Maintaining open communication with clients, families, and other
professionals.
Documentation: Maintaining accurate and comprehensive records of client
interactions and progress.
The term “social worker” is incorrect for this role.
55 DE OSOC Guidance Document on Opioid Use Disorder in the Emergency Department
Peer
Other titles:
Certified Peer
Recovery Specialist
Certified Family
Support
Peer
Principles for Peer Recovery Specialists are:
RECOVERY-ORIENTED: Peer Recovery Specialists hold out hope to those they serve, partnering
with them to envision and achieve a meaningful and purposeful life. Peers help those they
serve identify and build on strengths and empower them to choose for themselves,
recognizing that there are multiple pathways to recovery.
PERSON-CENTERED: Peer recovery support services are always directed by the person
participating in services. Peer recovery support is personalized to align with the specific hopes,
goals, and preferences of the individual served and to respond to specific needs the individuals
has identified to the peer worker.
VOLUNTARY: Peer Recovery Specialists are partners or consultants to those they serve. They
do not dictate the types of services provided or the elements of recovery plans that will guide
their work with peers. Participation in peer recovery support services is always contingent on
peer choice.
RELATIONSHIP-FOCUSED: The relationship between the peer recovery specialist and the client
served is the foundation on which peer recovery support services and support are provided.
The relationship between the peer and client is respectful, trusting, empathetic, collaborative,
and mutual.
TRAUMA-INFORMED: Peer recovery support utilizes a strengths-based framework that
emphasizes physical, psychological, and emotional safety and creates opportunities for
survivors to rebuild a sense of control and empowerment.
Core competencies of Peer Recovery Specialists:
Engages individuals in caring, collaborative relationships and provides support
Shares their lived experience of recovery
Personalizes peer support (person-centered planning) with focus on
individual/personal needs
Supports recovery planning with encouragement and forethought
Helps individuals manage crises
Links individuals to other resources, services, and supports beyond treatment and
SDOH
Shares information about health, wellness, and recovery
Values communication and supports teamwork
Promotes leadership and advocacy
Promotes self-growth and development
The Peer Recovery Specialist uses their own recovery experience and peer certification training
to assist clients with defining their recovery goals, and developing the skills and knowledge
needed for their recovery. The Peer Recovery Specialist will interact with many different types
56 DE OSOC Guidance Document on Opioid Use Disorder in the Emergency Department
of behavioral health and medical professionals while remaining true to the mission of peer
support. The Peer Recovery Specialist will advocate for clients while being in partnership with
other staff members.
Peers cannot treat, diagnose, case manage, or coordinate care.
The term “Peer Navigator” is considered incorrect