Buprenorphine on the Ambulance: Are Paramedics Ready to Treat Opioid Withdrawal Differently?
By Scott Ash
For The Paramedic Hive
For decades, the prehospital response to opioid overdose has followed a familiar sequence:
Find the patient.
Support ventilation.
Give naloxone.
Restore breathing.
Watch the patient wake up. And often wake up miserable.
The patient who was unresponsive minutes earlier may suddenly be vomiting, sweating, restless, anxious, cramping, aching, and begging you to make it stop. If naloxone abruptly displaced an opioid from the receptors, the patient may be experiencing significant acute withdrawal.
Historically, EMS has had little to offer beyond supportive care, treatment of individual symptoms, reassurance, and transport.
That is beginning to change.
A growing number of EMS systems are putting buprenorphine into the hands of appropriately trained paramedics—not simply as another medication for the drug box, but as a fundamentally unique way of thinking about the opioid patient.
From Reversing an Overdose to Treating the Patient
Naloxone is extraordinarily effective at what we ask it to do: reverse life-threatening opioid-induced respiratory depression.
But naloxone doesn’t treat opioid use disorder.
And it doesn’t necessarily solve what happens next.
The patient may awaken in withdrawal, refuse transport, walk away from EMS, and return to opioid use—sometimes specifically to relieve the withdrawal symptoms we just precipitated.
That creates an uncomfortable reality.
We may have successfully treated the emergency without meaningfully changing the disease process that produced it.
Buprenorphine offers a potential bridge between those two worlds.
Buprenorphine is a partial opioid agonist with remarkably high affinity for the mu-opioid receptor. When appropriately administered to a patient who is already experiencing opioid withdrawal, it can suppress withdrawal symptoms and cravings while having a more favorable safety profile than full opioid agonists.
And increasingly, that treatment is beginning before the ambulance reaches the hospital.
This Isn’t Just Theoretical Anymore
Recent EMS research is particularly interesting.
A 2025 study involving Hennepin EMS evaluated a paramedic-directed prehospital buprenorphine protocol. Among 121 patients, 82 were treated for naloxone-induced withdrawal and 39 for withdrawal following opioid cessation (Simpson Et al. 2025). Researchers reported no observed cases of precipitated withdrawal or worsening patient condition attributable to buprenorphine
San Francisco has also reported experience with prehospital buprenorphine-naloxone administration by EMS clinicians for patients with opioid use disorder experiencing acute withdrawal. This is no longer confined to isolated pilot projects. A 2025 review identified six statewide prehospital medication-for-opioid-use-disorder protocols plus regional protocols in 21 states and Washington, D.C. (Bornstein Et al 2025).
The protocols varied considerably in patient-selection criteria, dosing, medical-control requirements, and follow-up systems—which is important because there is not yet one universally accepted EMS approach.
Delaware went even further, implementing a statewide paramedic buprenorphine program across its ALS system. Its published two-year experience reported 105 patients receiving treatment between April 2023 and May 2025, with improvement in withdrawal symptoms reported following 63.6% of administered doses (Wanner, Et al 2025).
That should get the attention of EMS medical directors.
The Ambulance May Be an Important Treatment Window
There is another reason this concept deserves consideration.
The period immediately after an overdose may represents one of the rare moments when a person with opioid use disorder is directly connected with healthcare.
EMS is already there.
The patient doesn’t need to find transportation.
They don’t need an appointment.
They don’t need insurance authorization before someone talks to them.
They don’t even necessarily need to agree to an emergency department visit before the conversation begins.
The healthcare system has come directly to them
One study of paramedic-initiated buprenorphine found that patients encountering buprenorphine-equipped ambulances had substantially greater odds of engaging in opioid-use-disorder treatment within 30 days. Withdrawal scores also decreased after treatment, while average scene time increased by only about six minutes (Carroll, Et al, 2023).
Another community paramedicine program reported that 104 of 118 patients who began buprenorphine attended their first clinic appointment, with 68% staying engaged in care at 30 days (Belden Et al, 2024).
That is where this becomes bigger than simply treating nausea, diarrhea, muscle aches, or anxiety.
The paramedic may be initiating treatment for the underlying disorder.
But Buprenorphine Isn’t Just “Another Drug”
There is an important caution here.
Buprenorphine should not simply be added to the medication box with an instruction to “give for opioid withdrawal.”
Patient selection matters.
Timing matters.
Clinical assessment matters.
Recent opioid exposure matters.
Fentanyl complicates induction.
Methadone complicates induction.
Additionally, co-ingestants, polypharmacy and altered mental status can significantly complicate this picture. And because buprenorphine has a remarkably high receptor affinity, administering it under inappropriate circumstances can trigger precipitated withdrawal—a rapid and potentially severe worsening of withdrawal symptoms.
Published EMS protocols therefore commonly incorporate objective withdrawal assessments to evaluate such conditions. Most protocols require evidence of clinically significant withdrawal, although exact thresholds and dosing strategies vary considerably. This is precisely why prehospital buprenorphine should be implemented through an EMS medical director-approved protocol with appropriate education, quality improvement, and a pathway for continued treatment—not improvised by individual clinicians.
This Is Also About What We Believe Paramedics Are Capable Of
There is a larger professional question hidden inside this discussion.
What exactly do we want the modern paramedic to be?
If paramedicine is going to mature as a healthcare profession, our role cannot remain limited to stabilizing emergencies and delivering patients to somebody else’s healthcare system.
We already assess complex patients.
We differentiate shock states.
We interpret ECGs.
We manage difficult airways.
We administer controlled substances.
We make independent clinical decisions with limited information in uncontrolled environments.
Why shouldn’t appropriately educated paramedics also participate in evidence-based treatment of opioid use disorder?
Prehospital buprenorphine represents something EMS has historically struggled to embrace:
treating beyond the immediate emergency.
Instead of:
Overdose → naloxone → transport or refusal → goodbye
the model can potentially become:
Overdose → resuscitation → withdrawal assessment → appropriate buprenorphine initiation → linkage to continuing treatment.
That’s a very different philosophy of prehospital medicine.
The Next Step Is the Most Important One
Buprenorphine cannot solve the opioid crisis by itself.
And putting it on an ambulance without creating somewhere for that patient to go afterward misses much of the opportunity.
Successful programs require partnerships between EMS, emergency departments, addiction medicine, community clinics, peer-support specialists, public-health agencies, and medical directors.
The ambulance becomes the first link, not the entire chain.
But think about what that means.
A paramedic responding to an overdose at 2:00 in the morning may have an opportunity to do more than restore someone’s respiratory drive.
That paramedic may relieve the withdrawal that makes the patient desperate to use again.
They may start a medication proven useful in the treatment of opioid use disorder.
They may connect that patient with continuing treatment.
And potentially, the most important medication administered during that call may not have been the naloxone that woke the patient up.
It may have been the medication—and the pathway to treatment—that gave them somewhere to go afterward.
That is an expanded role for EMS worth discussing.
Because perhaps the future of paramedicine isn’t simply about saving patients from today’s emergency.
It is also about recognizing the opportunity to prevent tomorrow’s.
The Paramedic Hive
Built for Those Who Answer the Call.
References
Belden C 1st, Kopak A, Coules C, Friesen T, Hall J, Shukla S. Building bridges to outpatient treatment services for post-overdose care via paramedic buprenorphine field initiation. J Subst Use Addict Treat. 2024 Jul;162:209364. doi: 10.1016/j.josat.2024.209364. Epub 2024 Apr 16. PMID: 38626851.
Bornstein K, Rayburn D. Emergency Medical Services Utilization of Medication for Opioid Use Disorder: A Narrative Review of the Literature and Analysis of Prehospital Buprenorphine Protocols. Prehosp Emerg Care. 2025;29(4):407-419. doi: 10.1080/10903127.2025.2486292. Epub 2025 Apr 21. PMID: 40162803.
Carroll, Gerard, T. Solomon, Keisha, Heil, Jessica, Saloner, Brendan, A. Stuart, Elizabeth, Y. Patel, Esita, Greifer, Noah, Salzman, Matthew, Murphy, Emily, Baston, Kaitlan, Haroz, Rachel: Impact of Administering Buprenorphine to Overdose Survivors Using Emergency Medical Services, Annals of Emergency Medicine, Volume 81, Issue 2,2023, Pages 165-175, ISSN 0196-0644Retrieved from: https://www.sciencedirect.com/science/article/pii/S0196064422005066.
Simpson NS, Kummer TM, Drone HM, Perlmutter MC, Schin AM, Cole JB, Driver BE, Puskarich MA, Martin ME, Bunting AJ, Robinson AE. Feasibility and Safety of a Paramedic-Directed Prehospital Buprenorphine Initiation Protocol for Acute Opioid Withdrawal. Prehosp Emerg Care. 2025;29(4):427-434. doi: 10.1080/10903127.2024.2422897. Epub 2024 Nov 19. PMID: 39561297.
Wanner GK, Dworkin M, Rosenbaum RA. Statewide Prehospital Buprenorphine in Delaware: Two-Years of Paramedic-Initiated Medication for Opioid Use Disorder After Overdose. Dela J Public Health. 2025 Sep 26;11(3):24-28. doi: 10.32481/djph.2025.09.06. PMID: 41035727; PMCID: PMC12483363.
